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Bleeding in the HBR Patient Sunil V. Rao MD Disclosures n No - - PowerPoint PPT Presentation
Bleeding in the HBR Patient Sunil V. Rao MD Disclosures n No - - PowerPoint PPT Presentation
Best Practices for Reducing Procedural Bleeding in the HBR Patient Sunil V. Rao MD Disclosures n No relationships with industry n American Heart Association payment for role as Editor-in- Chief of Circulation: Cardiovascular Interventions n
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log rank p-value for all four categories <0.0001 log-rank p-value for no bleeding vs. mild bleeding = 0.02 log-rank p-value for mild vs. moderate bleeding <0.0001 log-rank p-value for moderate vs. severe <0.001
Bleeding & Outcomes
N=26,452 pts from PURSUIT, GUSTO IIb, PARAGON A & B
Rao SV, et al. Am J Cardiol. 2005
Kaplan Meier Curves for 30-Day Death, Stratified by Bleed Severity
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Access site and non-access site bleeding and outcomes
N=25 studies, 2.4 million pts
Kwok CS, et. al. Circ Intv 2015
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Bleeding – Mechanisms of harm & Strategies to reduce risk
Mechanisms
n Confounding
l
“Sick people bleed, and sick people die”
n Severe bleeding
l
Hypotension
l
Reversal of antithrombotic therapy
n Mild or Moderate bleeding
l
Cessation of antithrombotic therapy1
l
Blood transfusion2
Strategies
n Identify who is at risk so you can
use bleeding avoidance strategies
n Judicious use of blood transfusion n Pharmacotherapy n Vascular access
l
U/S for femoral access
l Radial access
1Wang TY, et. al. Circulation 2008 2Rao SV, et. al. JAMA 2004
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Who is at risk for bleeding?
n Older age n Female sex n Anemia n Low body weight n Poor renal function n Shock
Rao SV, et. al. JACC Intv 2013
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Bivalirudin vs. UFH ± 2b3a
N=16 RCTs, 33958 pts
Cavender MA, Sabatine MS. Lancet 2014
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FAUST Trial - Ultrasound guidance
N=1004 pts at 4 centers randomized to U/S or FG
Seto, AH. et. al. JACC Intv 2010
All patients receive manual palpation of landmarks U/S guidance – direct visualization of bifurcation and anterior arterial wall FG – radio-opaque marker placed and femoral head identified in AP projection
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Ultrasound guidance
N=1004 pts at 4 centers randomized to U/S or FG
Seto, AH. et. al. JACC Intv 2010
*P < 0.01
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Radial approach in ACS patients – bleeding and mortality
Pooled analysis of 4 trials, 17,133 pts
Andò G, Capodanno D. Annals of Internal Medicine 2015
Mortality
Major Bleeding Mortality
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SAFARI-STEMI
Mortality in STEMI pts in randomized trials
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Mechanism of mortality benefit
N=8404 pts in MATRIX trial
Prevention of AKI is the predominantly responsible for mortality benefit of radial NNT = 295
Rothenbüler M, et. al. EHJ 2019 Black bars denote mortality Gray bars denote nonfatal endpts
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Reducing procedural bleeding
Identify who is at risk – tools available Pay attention to pharmacotherapy Access site strategies U/S guidance especially for femoral approach Radial access
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