title: Association of bleeding, mortality and sex in acute coronary syndromes: the missing triangle.
abstract: OBJECTIVE
  Percutaneous coronary intervention (PCI) and antithrombotic drugs are the standard therapy for patients with acute coronary syndromes (ACS), but their impact on bleeding and mortality in women has not been adequately investigated.
  
  
  METHODS
  This was a prospective observational cohort study of ACS patients, who were referred to 6 of the 13 centres belonging to the REgistro regionale AngiopLastiche dell'Emilia-Romagna programme in Emilia-Romagna for coronary angiography and PCI between June 2010 and November 2011. The aim of the study was to verify whether the incidence of Global Registry of Acute Coronary Events-defined in-hospital bleeding after an ACS is significantly higher in women than in men, and to evaluate its impact on short and long-term mortality.
  
  
  RESULTS
  The analysis involved a total of 1686 patients (511 women and 1175 men). The women were older and more frequently affected by hypertension, congestive heart failure and single-vessel disease; however, none of the clinical or procedural variables was significantly different between the sexes after statistical adjustment. There was a significantly higher rate of in-hospital bleeding among the women [8.6 vs. 5.8%; adjusted odds ratio 1.73, 95% confidence interval (CI) 1.19-2.52, P = 0.004], but the adjusted hazard ratio for short and long-term all-cause mortality was not significantly different. After optimal adjustment, bleeding, but not female sex, was identified as a predictor of short-term all-cause mortality (hazard ratio 2.68, 95% CI 1.21-5.93, P = 0.01), but this was not confirmed in the case of long-term mortality (hazard ratio 1.57, 95% CI 0.91-2.71, P = 0.10).
  
  
  CONCLUSIONS
  After optimal adjustment for baseline differences, the findings of this contemporary Italian PCI registry study showed that women experience bleeding more frequently, but do not have worse mortality outcomes than men. Bleeding was confirmed as an independent predictor of short-term mortality.
authors.affiliation: aUnità Operativa di Cardiologia, Azienda Ospedaliero-Universitaria, Parma bIstituto di Cardiologia, Policlinico S. Orsola-Malpighi, Università di Bologna cAgenzia Sanitaria Regionale Regione Emilia-Romagna, Bologna dUnità Operativa di Cardiologia Interventistica, Ospedale Santa Maria Nuova, Reggio Emilia, Italy eZena and Michael A. Weiner Cardiovascular Institute, Mount Sinai School of Medicine, New York, USA fUnità Operativa Ricerca e Innovazione, Azienda Ospedaliero-Universitaria, Parma gUnità Operativa di Cardiologia, Ospedale Niguarda, Milan, Italy *Emilia Solinas and Luigi Vignali contributed equally to the writing of this article.
authors.forename: Emilia
authors.initials: E
authors.lastname: Solinas
authors.forename: Luigi
authors.initials: L
authors.lastname: Vignali
authors.forename: Paolo
authors.initials: P
authors.lastname: Ortolani
authors.forename: Paolo
authors.initials: P
authors.lastname: Guastaroba
authors.forename: Antonio
authors.initials: A
authors.lastname: Marzocchi
authors.forename: Antonio
authors.initials: A
authors.lastname: Manari
authors.forename: Rossana
authors.initials: R
authors.lastname: De Palma
authors.forename: Roxana
authors.initials: R
authors.lastname: Mehran
authors.forename: Giorgia
authors.initials: G
authors.lastname: Paoli
authors.forename: Maria Francesca
authors.initials: MF
authors.lastname: Notarangelo
authors.forename: Caterina
authors.initials: C
authors.lastname: Caminiti
authors.forename: Diego
authors.initials: D
authors.lastname: Ardissino
authors.forename: Piera Angelica
authors.initials: PA
authors.lastname: Merlini
mesh_terms: D054058:Acute Coronary Syndrome / Q000401:mortality / Q000628:therapy*; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006470:Hemorrhage / Q000209:etiology* / Q000401:mortality; D006760:Hospitalization; D006801:Humans; D007558:Italy / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects* / Q000401:mortality; D011446:Prospective Studies; D012042:Registries; D012737:Sex Factors