The Prognostic Value of Bleeding Academic Research Consortium (BARC) Defined Bleeding Complications in ST-Segment Elevation Myocardial Infarction: A Comparison With the Thrombolysis in Myocardial Infarction (TIMI), Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Arteries (GUSTO), and International Society of Thrombosis and Hemostasis (ISTH) Bleeding Classifications

Study Questions:

What is the relationship between Bleeding Academic Research Consortium (BARC) bleeding with 30-day and 1-year mortality, and how does the BARC bleeding definition compare to existing bleeding definitions with regard to prediction of mortality?

Methods:

This was a retrospective analysis of all ST-segment elevation myocardial infarction (STEMI) patients who underwent primary percutaneous coronary intervention (PCI) at a single-study center between January 2003 and July 2008. All hospitalizations were reviewed for bleeding outcomes. Bleeding events during the hospitalization were classified according to TIMI, GUSTO, ISTH, and BARC criteria. One-year mortality rates for the various bleeding categories were estimated for each bleeding classification.

Results:

The analytic sample was 2002 STEMI patients. In adjusted analyses, only TIMI major bleeding (including clinically significant overt signs of hemorrhage associated with a drop in hemoglobin >5 g/dl) and BARC type 3b (any transfusion with overt bleeding or overt bleeding plus hemoglobin drop ≥3 g/dl or <5 g/dl) or BARC type 3c (overt bleeding plus hemoglobin drop >5 g/dl, cardiac tamponade, bleeding requiring surgical intervention, bleeding requiring vasoactive agents) bleeding remained associated with a twofold higher risk of 1-year mortality. The addition of BARC, TIMI, GUSTO, or ISTH bleeding to a multivariable model did not improve the c-index.

Conclusions:

Although TIMI major bleeding and BARC type 3b or 3c bleeding were associated with a significant twofold higher risk of 1-year mortality, this finding did not translate into improvement in overall mortality prediction.

Perspective:

The limitations of this retrospective analysis aside, this is an important contribution that characterizes BARC-defined bleeding complications. The authors acknowledge that the addition of any bleeding definition to a multivariable model with baseline predictors of mortality did not improve the c-statistic, suggesting that ‘most of the excess mortality in patients with bleeding could be explained by factors associated with high mortality in patients with bleeding, such as cardiogenic shock and acute renal insufficiency.’

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Pericardial Disease

Keywords: Blood Transfusion, Blood Coagulation, Myocardial Infarction, Hemoglobins, Thrombosis, Hematologic Diseases, Fibrinolysis, Acute Kidney Injury, Angioplasty, Balloon, Coronary, Hemorrhage, Cardiac Tamponade, Percutaneous Coronary Intervention


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