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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|
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|
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|
|
|
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|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
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|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
A Oudot, P G Steg, N Danchin, G Dentan, M Zeller, P Sicard, P Buffet, Y Laurent, L Janin-Manificat, I L'Huillier, et al. Impact of chronic oral anticoagulation on management and outcomes of patients with acute myocardial infarction: data from the RICO survey Heart, August 1, 2006; 92(8): 1077 - 1083. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
 |
|
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|
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