Incidence, Prognostic Impact, and Influence of Antithrombotic Therapy on Access and Non-Access Site Bleeding in Percutaneous Coronary Intervention

Study Questions:

What are the incidence, predictors, and prognostic implications of access and nonaccess site bleeding in patients undergoing percutaneous coronary intervention (PCI)?


The authors pooled the patients (N = 17,393) enrolled in REPLACE-2 (Randomized Evaluation in PCI Linking Angiomax to Reduced Clinical Events), ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy), and HORIZONS-AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) trials and evaluated the impact of access versus nonaccess site bleeding.


Access site Thrombolysis in Myocardial Infarction (TIMI) major/minor bleeding occurred in 2.1% of all patients and nonaccess site bleeding was seen in 3.3% of the patients. Bleeding was a major predictor of 1-year mortality (hazard ratio [HR], 3.17; 95% confidence interval [CI], 2.51-4.00; p < 0.001). Nonaccess bleeding was a stronger predictor of mortality (HR, 3.94; 95% CI, 3.07-5.15; p < 0.0001) compared with access site bleeding (HR, 1.82; 95% CI, 1.17-2.83; p = 0.008). Randomization to bivalirudin was associated with a significant reduction in both access site (RR, 0.45; 95% CI, 0.35-0.58) and nonaccess bleeding (RR, 0.62; 95% CI, 0.51-0.75).


The authors concluded that compared with access site bleeding, nonaccess site bleeding is more common and is associated with a worse long-term mortality hazard.


Access site bleeding is now recognized as an important adverse outcome in patients undergoing PCI, although limited attention has been paid to nonaccess site bleeding. This study highlights the relative preponderance of nonaccess site bleeding and its deleterious impact on long-term survival. Meticulous access technique or use of transradial access would be expected to reduce access site bleeding, but reductions in nonaccess site bleeding would require attention to appropriate choice and dosing of pharmacotherapy. The relatively frequent occurrence of nonaccess bleeding and its strong association with long-term mortality invokes the need for focused efforts targeted toward reducing this complication.

Clinical Topics: Anticoagulation Management, Invasive Cardiovascular Angiography and Intervention

Keywords: Myocardial Infarction, Catheterization, Recombinant Proteins, Hirudins, Stents, Percutaneous Coronary Intervention

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