Copyright © 2003 by the European Society of Cardiology.
Clinical research
Predictors of major bleeding in acute coronary syndromes: the Global Registry of Acute Coronary Events (GRACE)
a University of Michigan Health System, Ann Arbor, Michigan, USA
b The Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
c Brigham and Women's Hospital, Boston, Massachusetts, UK
d Medizinische Universitätsklinik, Graz, Austria
e Hospital Universitario Gregorio Marañon, Madrid, Spain
f Pitié-Salpétrière Hospital, Paris, France
g University of Massachusetts Medical School, Worcester, Massachusetts, USA
* Address for correspondence: Dr Mauro Moscucci, University of Michigan Medical Center, Department of Internal Medicine/Cardiology, Taubman Center B1226, 1500 East Medical Center Drive, Ann Arbor, Michigan 48109-0311, USA. Tel: +1-734-615-3528; Fax: +1-734-764-4142
E-mail address: moscucci{at}umich.edu
Received 2 January 2003; revised 3 July 2003; accepted 31 July 2003
Abstract
Aims There have been no large observational studies attempting to identify predictors of major bleeding in patients with acute coronary syndromes (ACS), particularly from a multinational perspective. The objective of our study was thus to develop a prediction rule for the identification of patients with ACS at higher risk of major bleeding.
Methods and results Data from 24 045 patients from the Global Registry of Acute Coronary Events (GRACE) were analysed. Factors associated with major bleeding were identified using logistic regression analysis. Predictive models were developed for the overall patient population and for subgroups of patients with ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina. The overall incidence of major bleeding was 3.9% (4.8% in patients with STEMI, 4.7% in patients with NSTEMI and 2.3% in patients with unstable angina). Advanced age, female sex, history of bleeding, and renal insufficiency were independently associated with a higher risk of bleeding (P<0.01). The association remained after adjustment for hospital therapies and performance of invasive procedures. After adjustment for a variety of potential confounders, major bleeding was significantly associated with an increased risk of hospital death (adjusted odds ratio 1.64, 95% confidence interval 1.18, 2.28).
Conclusions In routine clinical practice, major bleeding is a relatively frequent non-cardiac complication of contemporary therapy for ACS and it is associated with a poor hospital prognosis. Simple baseline demographic and clinical characteristics identify patients at increased risk of major bleeding.
Key Words: Major bleeding • acute coronary syndromes • complications • myocardial infarction • unstable angina
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K. P. Alexander, A. Y. Chen, M. T. Roe, L. K. Newby, C. M. Gibson, N. M. Allen-LaPointe, C. Pollack, W. B. Gibler, E. M. Ohman, E. D. Peterson, et al. Excess Dosing of Antiplatelet and Antithrombin Agents in the Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes JAMA, December 28, 2005; 294(24): 3108 - 3116. [Abstract] [Full Text] [PDF]
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J.-P. Collet, G. Montalescot, G. Agnelli, F. Van de Werf, E. P. Gurfinkel, J. Lopez-Sendon, C. V. Laufenberg, M. Klutman, N. Gowda, D. Gulba, et al. Non-ST-segment elevation acute coronary syndrome in patients with renal dysfunction: benefit of low-molecular-weight heparin alone or with glycoprotein IIb/IIIa inhibitors on outcomes. The Global Registry of Acute Coronary Events Eur. Heart J., November 1, 2005; 26(21): 2285 - 2293. [Abstract] [Full Text] [PDF]
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K. P. Alexander, M. T. Roe, A. Y. Chen, B. L. Lytle, C. V. Pollack Jr, J. M. Foody, W. E. Boden, S. C. Smith Jr, W. B. Gibler, E. M. Ohman, et al. Evolution in Cardiovascular Care for Elderly Patients With Non-ST-Segment Elevation Acute Coronary Syndromes: Results From the CRUSADE National Quality Improvement Initiative J. Am. Coll. Cardiol., October 18, 2005; 46(8): 1479 - 1487. [Abstract] [Full Text] [PDF]
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X. Yang, K. P. Alexander, A. Y. Chen, M. T. Roe, R. G. Brindis, S. V. Rao, W. B. Gibler, E. M. Ohman, E. D. Peterson, and for the CRUSADE Investigators The Implications of Blood Transfusions for Patients With Non-ST-Segment Elevation Acute Coronary Syndromes: Results From the CRUSADE National Quality Improvement Initiative J. Am. Coll. Cardiol., October 18, 2005; 46(8): 1490 - 1495. [Abstract] [Full Text] [PDF]
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 S. A. Spinler, P. Dobesh, C. Macie, and J. Douketis Dose Capping Enoxaparin Is Unjustified and Denies Patients With Acute Coronary Syndromes a Potentially Effective Treatment Chest, June 1, 2005; 127(6): 2288 - 2290. [Full Text] [PDF]
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 A. Galli and A. Palatnik What is the proper activated clotting time (ACT) at which to remove a femoral sheath after PCI? What are the best "protocols" for sheath removal? Crit. Care Nurse, April 1, 2005; 25(2): 88 - 5. [Full Text] [PDF]
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G. Montalescot, J.P. Collet, M.L. Tanguy, A. Ankri, L. Payot, R. Dumaine, R. Choussat, F. Beygui, V. Gallois, and D. Thomas Anti-Xa Activity Relates to Survival and Efficacy in Unselected Acute Coronary Syndrome Patients Treated With Enoxaparin Circulation, July 27, 2004; 110(4): 392 - 398. [Abstract] [Full Text] [PDF]
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