title: Association of spontaneous bleeding and myocardial infarction with long-term mortality after percutaneous coronary intervention.
abstract: BACKGROUND
  Platelet inhibition after percutaneous coronary intervention (PCI) reduces the risk of myocardial infarction (MI) but increases the risk of bleeding. MIs and bleeds during the index hospitalization for PCI are known to negatively affect long-term outcomes. The impact of spontaneous bleeding occurring after discharge on long-term mortality is unknown.
  
  
  OBJECTIVE
  This study sought to examine, in a real-world cohort, the association between spontaneous major bleeding or MI after PCI and long-term mortality.
  
  
  METHODS
  We conducted a retrospective cohort study of patients ≥30 years of age who underwent a PCI between 1996 and 2008 in an integrated healthcare delivery system. We used extended Cox regression to examine the associations of spontaneous bleeding and MI with all-cause mortality, after adjustment for time-updated demographics, comorbidities, periprocedural events, and longitudinal medication exposure.
  
  
  RESULTS
  Among 32,906 patients who had a PCI and survived the index hospitalization, 530 had bleeds and 991 had MIs between 7 and 365 days post-discharge. There were 4,048 deaths over a mean follow-up of 4.42 years. The crude annual death rate after a spontaneous bleed (9.5%) or MI (7.6%) was higher than among patients who experienced neither event (2.6%). Bleeding was associated with an increased rate of death (adjusted hazard ratio [HR]: 1.61, 95% confidence interval [CI]: 1.30 to 2.00), similar to that after an MI (HR: 1.91; 95% CI: 1.62 to 2.25). The association of bleeding with death remained significant after additional adjustment for the longitudinal use of antiplatelet agents.
  
  
  CONCLUSIONS
  Spontaneous bleeding after a PCI was independently associated with higher long-term mortality, and conveyed a risk comparable to that of an MI during follow-up. This tradeoff between efficacy and safety bolsters the argument for personalizing antiplatelet therapy after PCI on the basis of the patient's long-term risk of both thrombotic and bleeding events.
authors: Division of Cardiology, San Francisco General Hospital, San Francisco, California; Department of Medicine (Cardiology), University of California San Francisco, San Francisco, California; Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California. Electronic address: kazi@ucsf.edu.
authors: Dhruv S
authors: DS
authors: Kazi
authors: Division of Research, Kaiser Permanente Northern California, Oakland, California.
authors: Thomas K
authors: TK
authors: Leong
authors: Department of Medicine, Stanford University, Stanford, California.
authors: Tara I
authors: TI
authors: Chang
authors: Division of Research, Kaiser Permanente Northern California, Oakland, California; Department of Medicine, Stanford University, Stanford, California.
authors: Matthew D
authors: MD
authors: Solomon
authors: Department of Medicine, Stanford University, Stanford, California; Department of Health Research and Policy, Stanford University, Stanford, California.
authors: Mark A
authors: MA
authors: Hlatky
authors: Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California; Division of Research, Kaiser Permanente Northern California, Oakland, California; Department of Health Research and Policy, Stanford University, Stanford, California.
authors: Alan S
authors: AS
authors: Go
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D009026:Mortality / Q000639:trends*; D009203:Myocardial Infarction / Q000175:diagnosis / Q000401:mortality*; D062645:Percutaneous Coronary Intervention / Q000401:mortality*; D019106:Postoperative Hemorrhage / Q000175:diagnosis / Q000401:mortality*; D012189:Retrospective Studies
keywords: antiplatelet agents; health outcomes; health services research; hemorrhage; personalized medicine