Perspective:

The following are 10 points to remember about this position paper:

1. Bleeding is an important predictor of adverse short- and long-term outcome in patients with acute coronary syndromes (ACS) and those undergoing percutaneous coronary intervention (PCI).

2. The major predictors of bleeding are advanced age, female gender, diminished renal function, low body weight, and use of invasive procedures.

3. Genetic factors may predispose some patients to bleeding by impacting pharmacokinetics of different antithrombotic or antiplatelet agents.

4. The deleterious impact of bleeding may be related to a casual link with factors that increase long-term ischemic risk, direct deleterious impact (hypotension, anemia, and reduced oxygen delivery), discontinuation of antithrombotic drugs, and negative impacts of transfusion.

5. Transfusion is associated with increased platelet aggregation, impaired oxygen and nitric oxide delivery, and increased inflammation.

6. Restricted transfusion policies are associated with better outcome compared with an approach of liberal transfusion. Moderate anemia is often well tolerated in patients who do not have obstructive coronary artery disease.

7. In patients undergoing PCI, about one half of the bleeding events are related to access site. Nonaccess site bleeding is more strongly associated with long-term mortality compared with access site bleeding.

8. Radial access and appropriate choice and dose of anticoagulation therapy can reduce the risk of access site bleeding. This is especially important for patients with abnormal renal function who are at both increased risk for bleeding as well as at risk of medication overdosing due to altered pharmacokinetics.

9. Lower risk of bleeding has been achieved with use of fondaparinux instead of enoxaparin in non–ST-segment elevation myocardial infarction ACS, and use of bivalirudin compared with unfractionated heparin and glycoprotein IIb/IIIa inhibitors in patients undergoing PCI.

10. Gastrointestinal bleeding is common in patients with ACS and those undergoing PCI. Use of proton pump inhibitors should be considered in patients on dual antiplatelet therapy if they have prior history of upper gastrointestinal tract bleeding, advanced age; concomitant use of warfarin, steroids, or nonsteroidal anti-inflammatory drugs; or H. pylori infection.