Incidence, Predictors, and Impact of Post-Discharge Bleeding After Percutaneous Coronary Intervention.

Philippe Généreux MD
Gennaro Giustino MD
Bernhard Witzenbichler MD
Giora Weisz MD
Thomas D. Stuckey MD
Michael J. Rinaldi MD
Franz-Josef Neumann MD
D Christopher Metzger MD
Timothy D. Henry MD
David A. Cox MD, Lehigh Valley Health Network
Peter L. Duffy MD
Ernest L. Mazzaferri MD
Mayank Yadav
Dominic P. Francese MPH
Tullio Palmerini
Ajay J. Kirtane MD
Claire Litherland MS
Roxana Mehran MD
Gregg W. Stone MD


BACKGROUND: The incidence, predictors, and prognostic impact of post-discharge bleeding (PDB) after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation are unclear.

OBJECTIVES: This study sought to characterize the determinants and consequences of PDB after PCI.

METHODS: The prospective ADAPT-DES (Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents) study was used to determine the incidence and predictors of clinically relevant bleeding events occurring within 2 years after hospital discharge. The effect of PDB on subsequent 2-year all-cause mortality was estimated by time-adjusted Cox proportional hazards regression.

RESULTS: Among 8,582 "all-comers" who underwent successful PCI with DES in the ADAPT-DES study, PDB occurred in 535 of 8,577 hospital survivors (6.2%) at a median time of 300 days (interquartile range: 130 to 509 days) post-discharge. Gastrointestinal bleeding (61.7%) was the most frequent source of PDB. Predictors of PDB included older age, lower baseline hemoglobin, lower platelet reactivity on clopidogrel, and use of chronic oral anticoagulation therapy. PDB was associated with higher crude rates of all-cause mortality (13.0% vs. 3.2%; p < 0.0001). Following multivariable adjustment, PDB was strongly associated with 2-year mortality (hazard ratio [HR]: 5.03; p < 0.0001), with an effect size greater than that of post-discharge myocardial infarction (PDMI) (HR: 1.92; p = 0.009).

CONCLUSIONS: After successful PCI with DES in an unrestricted patient population, PDB is not uncommon and has a strong relationship with subsequent all-cause mortality, greater that that associated with PDMI. Efforts to reduce PDB may further improve prognosis after successful DES implantation. (Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents [ADAPT-DES]; NCT00638794).