Perspective:

Bleeding after PCI has been associated with increased morbidity, cost, and mortality, and has been designated as a quality metric in the Centers for Medicare and Medicaid Services Acute Care Episode Demonstration program. Although it remains to be established whether the association between bleeding and mortality is causal, there is going to be greater scrutiny of bleeding as a post-PCI complication in the near-term. This study found that the widest variation in bleeding was seen with respect to decline in hemoglobin of >3 g/dl. This endpoint is most susceptible to variation in hydration status as well as ascertainment bias, and has the least clinical significance (compared with other components of the bleeding definition). While efforts to minimize bleeding are always worthwhile, the modest association of bleeding avoidance strategies with the hospital-level bleeding rate suggests that other unknown factors explain the majority of the observed differences in bleeding rates. Accordingly, it may be premature to consider bleeding as a completely preventable event or to link hospital-level bleeding incidence to reimbursement.