title: Prognostic significance of bleeding location and severity among patients with acute coronary syndromes.
abstract: OBJECTIVE
  This study sought to determine if there is an association between bleed location and clinical outcomes in acute coronary syndromes (ACS) patients.
  
  
  BACKGROUND
  The prognostic significance of bleeding location among ACS patients undergoing cardiac catheterization is not well known.
  
  
  METHODS
  We analyzed in-hospital bleeding events among 9,978 patients randomized in the SYNERGY (Superior Yield of the New Strategy of Enoxaparin, Revascularization, and Glycoprotein IIb/IIIa Inhibitors) study. Bleeding events were categorized by location as access site, systemic, surgical, or superficial, and severity was graded using the GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries) definition. We assessed the association of each bleeding location and severity with 6-month risk of death or myocardial infarction using a multicovariate-adjusted Cox proportional hazard model.
  
  
  RESULTS
  A total of 4,900 bleeding events were identified among 3,694 ACS patients with in-hospital bleeding. Among 4,679 GUSTO mild/moderate bleeding events, only surgical and systemic bleeds were associated with an increased risk of 6-month death or myocardial infarction (adjusted hazard ratio [HR]: 2.52 [95% confidence interval (CI): 2.16 to 2.94, and 1.40 [95% CI: 1.16 to 1.69], respectively). Mild/moderate superficial and access-site bleeds were not associated with downstream risk (adjusted HR: 1.17 [95% CI: 0.97 to 1.40], and 0.96 [95% CI: 0.82 to 1.12], respectively). Among 221 GUSTO severe bleeds, surgical bleeds were associated with the highest risk (HR: 5.27 [95% CI: 3.80 to 7.29]), followed by systemic (HR: 4.48 [95% CI: 2.98 to 6.72]), and finally access-site bleeds (HR: 3.57 [95% CI: 2.35 to 5.40]).
  
  
  CONCLUSIONS
  Among ACS patients who develop in-hospital bleeding, systemic and surgical bleeding are associated with the highest risks of adverse outcomes regardless of bleeding severity. Although the most frequent among bleeds, GUSTO mild/moderate access-site bleeding is not associated with increased risk. These data underscore the importance of strategies to minimize overall bleeding risk beyond vascular access site management.
authors.affiliation: Duke Clinical Research Institute, Durham, North Carolina 27705, USA. john.vavalle@duke.edu
authors.forename: John P
authors.initials: JP
authors.lastname: Vavalle
authors.forename: Robert
authors.initials: R
authors.lastname: Clare
authors.forename: Karen
authors.initials: K
authors.lastname: Chiswell
authors.forename: Sunil V
authors.initials: SV
authors.lastname: Rao
authors.forename: John L
authors.initials: JL
authors.lastname: Petersen
authors.forename: Neal S
authors.initials: NS
authors.lastname: Kleiman
authors.forename: Kenneth W
authors.initials: KW
authors.lastname: Mahaffey
authors.forename: Tracy Y
authors.initials: TY
authors.lastname: Wang
mesh_terms: D054058:Acute Coronary Syndrome / Q000401:mortality / Q000628:therapy*; D000368:Aged; D000925:Anticoagulants / Q000009:adverse effects*; D016063:Blood Loss, Surgical / Q000401:mortality; D001026:Coronary Artery Bypass / Q000009:adverse effects* / Q000401:mortality; D017984:Enoxaparin / Q000009:adverse effects*; D005260:Female; D006470:Hemorrhage / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality; D006760:Hospitalization; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000209:etiology / Q000401:mortality; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects* / Q000401:mortality; D010975:Platelet Aggregation Inhibitors / Q000009:adverse effects*; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors / Q000378:metabolism; D019106:Postoperative Hemorrhage / Q000209:etiology / Q000401:mortality; D016016:Proportional Hazards Models; D011677:Punctures; D016032:Randomized Controlled Trials as Topic; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants; D017984:Enoxaparin; D010975:Platelet Aggregation Inhibitors; D019039:Platelet Glycoprotein GPIIb-IIIa Complex
keywords: ACS; CABG; CI; GP; HR; IQR; MI; PCI; TIMI; Thrombolysis In Myocardial Infarction; acute coronary syndrome; acute coronary syndromes; bleeding; confidence interval(s); coronary artery bypass graft; glycoprotein; hazard ratio(s); interquartile range; myocardial infarction; percutaneous coronary intervention