Physicians successfully reversed the bleeding risk-treatment paradox in percutaneous coronary intervention (PCI) by prioritizing risk-concordant use of bleeding avoidance strategies (BAS) like bivalirudin, radial access and vascular closure devices (VCDs), according to a study published Oct. 31 in the Journal of the American Heart Association.
The risk-treatment paradox—the idea that patients at the highest risk of bleeding during a PCI procedure paradoxically receive the least amount of BAS—is an important one in PCI, since bleeding is the intervention’s most common complication and affects up to a tenth of its patients each year.
“There have been few efforts to reverse the bleeding risk-treatment paradox,” corresponding author Amit P. Amin, MD, MSc, and colleagues wrote in JAHA. “In spite of the observation over the past few years that the use of transradial access demonstrates an increasing trend, systematic-based use of BAS is far from established and, in fact, demonstrates a large risk-treatment paradox.”
Amin and colleagues at Washington University School of Medicine in St. Louis tested the utility of a patient-centered intervention in elevating rates of risk-concordant BAS use during 3,519 PCIs at Barnes-Jewish Hospital. Before a physician decided on choice of access and anticoagulant use for the procedure, the intraprocedural nurse in the room performed a “mandatory time-out” to communicate predicted bleeding risk as calculated by a decision aid, “with a hard stop to not proceed unless the bleeding risk was acknowledged by the attending physician.”
For the purposes of the study, BAS were considered either bivalirudin, radial access or use of VCDs. After implementing the intervention, Amin et al. said risk-concordant use of BAS rose significantly, which was reflected in the 2 percent bleeding incidence in that group of patients. Bleeding rates reached 9 percent in the risk-discordant group.
Risk-concordant use of BAS was also linked to a 67 percent reduced risk of bleeding and an average $4,738 reduction in per-patient PCI hospitalization costs, according to the data. That translated to a mean cost-savings of 21.6 percent.
“By focusing on risk of bleeding at the point of care, it was feasible to impact but also difficult to fully reverse the risk-treatment paradox,” Amin and coauthors wrote. “Nonetheless, even partial reductions in the risk-treatment paradox, achieved by the risk-concordant use of BAS, were associated with substantial reductions in the incidence of bleeding and hospital costs.”