title: Access and non-access site bleeding after percutaneous coronary intervention and risk of subsequent mortality and major adverse cardiovascular events: systematic review and meta-analysis.
abstract: BACKGROUND
  The prognostic impact of site-specific major bleeding complications after percutaneous coronary intervention (PCI) has yielded conflicting data. The aim of this study is to provide an overview of site-specific major bleeding events in contemporary PCI and study their impact on mortality and major adverse cardiovascular event outcomes.
  
  
  RESULTS
  We conducted a meta-analysis of PCI studies that evaluated site-specific periprocedural bleeding complications and their impact on major adverse cardiovascular events and mortality outcomes. A systematic search of MEDLINE and Embase was conducted to identify relevant studies and random effects meta-analysis was used to estimate the risk of adverse outcomes with site-specific bleeding complications. Twenty-five relevant studies including 2,400,645 patients that underwent PCI were identified. Both non-access site (risk ratio [RR], 4.06; 95% confidence interval [CI], 3.21-5.14) and access site (RR, 1.71; 95% CI, 1.37-2.13) related bleeding complications were independently associated with an increased risk of periprocedural mortality. The prognostic impact of non-access site-related bleeding events on mortality related to the source of anatomic bleeding, for example, gastrointestinal RR, 2.78; 95% CI, 1.25 to 6.18; retroperitoneal RR, 5.87; 95% CI, 1.63 to 21.12; and intracranial RR, 22.71; 95% CI, 12.53 to 41.15.
  
  
  CONCLUSIONS
  The prognostic impact of bleeding complications after PCI varies according to anatomic source and severity. Non-access site-related bleeding complications have a similar prevalence to those from the access site but are associated with a significantly worse prognosis partly related to the severity of the bleed. Clinicians should minimize the risk of major bleeding complications during PCI through judicious use of bleeding avoidance strategies irrespective of the access site used.
authors.affiliation: From the Cardiovascular Institute (C.S.K., M.A.M.), Institute of Population Health (M.S., I.B.), and Farr Institute (M.S., I.B., M.A.M.), University of Manchester, Manchester, United Kingdom; Manchester Heart Centre, Central Manchester NHS Foundation Trust, Manchester, Lancashire, United Kingdom (M.A.K., M.A.M.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.V.R.); Department of Cardiology, University Hospital of Wales, Cardiff, Wales, United Kingdom (T.K.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, North Yorkshire, United Kingdom (M.A.d.B.); Department of Cardiology, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom (P.F.L.); Department of Cardiology, University Hospital North Midlands, Stoke-on-Trent, Staffordshire, United Kingdom (J.N.); and Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Y.K.L.).
authors.forename: Chun Shing
authors.initials: CS
authors.lastname: Kwok
authors.affiliation: From the Cardiovascular Institute (C.S.K., M.A.M.), Institute of Population Health (M.S., I.B.), and Farr Institute (M.S., I.B., M.A.M.), University of Manchester, Manchester, United Kingdom; Manchester Heart Centre, Central Manchester NHS Foundation Trust, Manchester, Lancashire, United Kingdom (M.A.K., M.A.M.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.V.R.); Department of Cardiology, University Hospital of Wales, Cardiff, Wales, United Kingdom (T.K.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, North Yorkshire, United Kingdom (M.A.d.B.); Department of Cardiology, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom (P.F.L.); Department of Cardiology, University Hospital North Midlands, Stoke-on-Trent, Staffordshire, United Kingdom (J.N.); and Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Y.K.L.).
authors.forename: Muhammad A
authors.initials: MA
authors.lastname: Khan
authors.affiliation: From the Cardiovascular Institute (C.S.K., M.A.M.), Institute of Population Health (M.S., I.B.), and Farr Institute (M.S., I.B., M.A.M.), University of Manchester, Manchester, United Kingdom; Manchester Heart Centre, Central Manchester NHS Foundation Trust, Manchester, Lancashire, United Kingdom (M.A.K., M.A.M.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.V.R.); Department of Cardiology, University Hospital of Wales, Cardiff, Wales, United Kingdom (T.K.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, North Yorkshire, United Kingdom (M.A.d.B.); Department of Cardiology, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom (P.F.L.); Department of Cardiology, University Hospital North Midlands, Stoke-on-Trent, Staffordshire, United Kingdom (J.N.); and Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Y.K.L.).
authors.forename: Sunil V
authors.initials: SV
authors.lastname: Rao
authors.affiliation: From the Cardiovascular Institute (C.S.K., M.A.M.), Institute of Population Health (M.S., I.B.), and Farr Institute (M.S., I.B., M.A.M.), University of Manchester, Manchester, United Kingdom; Manchester Heart Centre, Central Manchester NHS Foundation Trust, Manchester, Lancashire, United Kingdom (M.A.K., M.A.M.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.V.R.); Department of Cardiology, University Hospital of Wales, Cardiff, Wales, United Kingdom (T.K.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, North Yorkshire, United Kingdom (M.A.d.B.); Department of Cardiology, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom (P.F.L.); Department of Cardiology, University Hospital North Midlands, Stoke-on-Trent, Staffordshire, United Kingdom (J.N.); and Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Y.K.L.).
authors.forename: Tim
authors.initials: T
authors.lastname: Kinnaird
authors.affiliation: From the Cardiovascular Institute (C.S.K., M.A.M.), Institute of Population Health (M.S., I.B.), and Farr Institute (M.S., I.B., M.A.M.), University of Manchester, Manchester, United Kingdom; Manchester Heart Centre, Central Manchester NHS Foundation Trust, Manchester, Lancashire, United Kingdom (M.A.K., M.A.M.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.V.R.); Department of Cardiology, University Hospital of Wales, Cardiff, Wales, United Kingdom (T.K.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, North Yorkshire, United Kingdom (M.A.d.B.); Department of Cardiology, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom (P.F.L.); Department of Cardiology, University Hospital North Midlands, Stoke-on-Trent, Staffordshire, United Kingdom (J.N.); and Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Y.K.L.).
authors.forename: Matt
authors.initials: M
authors.lastname: Sperrin
authors.affiliation: From the Cardiovascular Institute (C.S.K., M.A.M.), Institute of Population Health (M.S., I.B.), and Farr Institute (M.S., I.B., M.A.M.), University of Manchester, Manchester, United Kingdom; Manchester Heart Centre, Central Manchester NHS Foundation Trust, Manchester, Lancashire, United Kingdom (M.A.K., M.A.M.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.V.R.); Department of Cardiology, University Hospital of Wales, Cardiff, Wales, United Kingdom (T.K.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, North Yorkshire, United Kingdom (M.A.d.B.); Department of Cardiology, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom (P.F.L.); Department of Cardiology, University Hospital North Midlands, Stoke-on-Trent, Staffordshire, United Kingdom (J.N.); and Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Y.K.L.).
authors.forename: Iain
authors.initials: I
authors.lastname: Buchan
authors.affiliation: From the Cardiovascular Institute (C.S.K., M.A.M.), Institute of Population Health (M.S., I.B.), and Farr Institute (M.S., I.B., M.A.M.), University of Manchester, Manchester, United Kingdom; Manchester Heart Centre, Central Manchester NHS Foundation Trust, Manchester, Lancashire, United Kingdom (M.A.K., M.A.M.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.V.R.); Department of Cardiology, University Hospital of Wales, Cardiff, Wales, United Kingdom (T.K.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, North Yorkshire, United Kingdom (M.A.d.B.); Department of Cardiology, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom (P.F.L.); Department of Cardiology, University Hospital North Midlands, Stoke-on-Trent, Staffordshire, United Kingdom (J.N.); and Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Y.K.L.).
authors.forename: Mark A
authors.initials: MA
authors.lastname: de Belder
authors.affiliation: From the Cardiovascular Institute (C.S.K., M.A.M.), Institute of Population Health (M.S., I.B.), and Farr Institute (M.S., I.B., M.A.M.), University of Manchester, Manchester, United Kingdom; Manchester Heart Centre, Central Manchester NHS Foundation Trust, Manchester, Lancashire, United Kingdom (M.A.K., M.A.M.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.V.R.); Department of Cardiology, University Hospital of Wales, Cardiff, Wales, United Kingdom (T.K.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, North Yorkshire, United Kingdom (M.A.d.B.); Department of Cardiology, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom (P.F.L.); Department of Cardiology, University Hospital North Midlands, Stoke-on-Trent, Staffordshire, United Kingdom (J.N.); and Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Y.K.L.).
authors.forename: Peter F
authors.initials: PF
authors.lastname: Ludman
authors.affiliation: From the Cardiovascular Institute (C.S.K., M.A.M.), Institute of Population Health (M.S., I.B.), and Farr Institute (M.S., I.B., M.A.M.), University of Manchester, Manchester, United Kingdom; Manchester Heart Centre, Central Manchester NHS Foundation Trust, Manchester, Lancashire, United Kingdom (M.A.K., M.A.M.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.V.R.); Department of Cardiology, University Hospital of Wales, Cardiff, Wales, United Kingdom (T.K.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, North Yorkshire, United Kingdom (M.A.d.B.); Department of Cardiology, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom (P.F.L.); Department of Cardiology, University Hospital North Midlands, Stoke-on-Trent, Staffordshire, United Kingdom (J.N.); and Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Y.K.L.).
authors.forename: James
authors.initials: J
authors.lastname: Nolan
authors.affiliation: From the Cardiovascular Institute (C.S.K., M.A.M.), Institute of Population Health (M.S., I.B.), and Farr Institute (M.S., I.B., M.A.M.), University of Manchester, Manchester, United Kingdom; Manchester Heart Centre, Central Manchester NHS Foundation Trust, Manchester, Lancashire, United Kingdom (M.A.K., M.A.M.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.V.R.); Department of Cardiology, University Hospital of Wales, Cardiff, Wales, United Kingdom (T.K.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, North Yorkshire, United Kingdom (M.A.d.B.); Department of Cardiology, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom (P.F.L.); Department of Cardiology, University Hospital North Midlands, Stoke-on-Trent, Staffordshire, United Kingdom (J.N.); and Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Y.K.L.).
authors.forename: Yoon K
authors.initials: YK
authors.lastname: Loke
authors.affiliation: From the Cardiovascular Institute (C.S.K., M.A.M.), Institute of Population Health (M.S., I.B.), and Farr Institute (M.S., I.B., M.A.M.), University of Manchester, Manchester, United Kingdom; Manchester Heart Centre, Central Manchester NHS Foundation Trust, Manchester, Lancashire, United Kingdom (M.A.K., M.A.M.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.V.R.); Department of Cardiology, University Hospital of Wales, Cardiff, Wales, United Kingdom (T.K.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, North Yorkshire, United Kingdom (M.A.d.B.); Department of Cardiology, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom (P.F.L.); Department of Cardiology, University Hospital North Midlands, Stoke-on-Trent, Staffordshire, United Kingdom (J.N.); and Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Y.K.L.). mamasmamas1@yahoo.co.uk.
authors.forename: Mamas A
authors.initials: MA
authors.lastname: Mamas
mesh_terms: D006801:Humans; D062645:Percutaneous Coronary Intervention; D019106:Postoperative Hemorrhage / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D012306:Risk; D016019:Survival Analysis
keywords: cardiovascular disease; hemorrhage; percutaneous coronary intervention