Major bleeding is associated with subsequent major adverse cardiac and cerebrovascular events (MACCE) and death in patients with atrial fibrillation (AFib) and stable coronary artery disease (CAD), according to new data published in Circulation: Cardiovascular Interventions.
“Preventing bleeding is an established aim discussed widely even in recent guidelines for optimal antithrombotic therapy,” wrote lead author Koichi Kaikita, MD, PhD, of the University of Miyazaki in Japan, and colleagues. “Some subanalyses and meta-analyses demonstrated that bleeding during hospitalization or after discharge following percutaneous coronary intervention (PCI) was closely associated with an increased risk of death and myocardial infarction. However, the impacts of early bleeding after PCI remain unclear in patients with AFib and stable CAD.”
The authors examined data from previously completed AFIRE trial, focusing on more than 2,200 patients enrolled at 294 different facilities. Seventy-nine percent of patients were men, and the mean patient age was 74 years old. There was a median follow-up period of 24.1 months. A MACCE was defined as "a composite of stroke, systemic embolism, myocardial infarction, unstable angina requiring revascularization, or death from any cause."
All patients included in the study had a history of PCI, coronary artery bypass grafting (CABG) or angiographically confirmed CAD that did not require revascularization within one year of enrollment.
Hypertension was reported in 85.4% of patients, heart failure was reported in 35.6% of patients and a history of stroke was reported in 14.6% of patients.
The percentages of patients who underwent PCI and CABG were 70.6% and 11.4%, respectively, while the remaining patients did not require revascularization.
Overall, 17.4% of patients had bleeding during follow-up, and 16.3% of those patients also had a MACCE. The frequency of MACCE was nearly twice as high among patients with bleeding events, and 73% of patients had both a bleeding event and a subsequent MACCE.
Also, among patients with both bleeding and a MACCE, the bleeding event came first 73% of the time.
The most commonly reported MACCEs after bleeding were death from any cause and ischemic stroke.
The authors also found that, within seven days after major bleeding, anticoagulant therapy was stopped in 32 patients; one-fourth of those patients had a MACCE after the anticoagulant therapy was stopped. On a similar note, antiplatelet agents were discontinued within seven days after a major bleeding event. One-third of those patients had a MACCE after the antiplatelet agents were discontinued.
When examining the temporal association between bleeding and subsequent MACCE, the authors found that among patients who experienced major bleeding, 22.6% developed a MACCE. Among patients with minor bleeding, 7.8% developed a MACC.
A time-adjusted multivariate analysis revealed that major bleeding was linked to a patient's MACCE risk within the next 30 days.T This was not true for minor bleeding, however.
“Our findings suggest that it is important to monitor and manage the bleeding risk to balance the prevention of cardiovascular events, death, and bleeding with respect to the selection of optimal antithrombotic therapy in patients with AFib and stable CAD,” the authors wrote.
Read the full study here.