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Incidence and impact on prognosis of bleeding during percutaneous coronary interventions in patients with chronic kidney disease

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Abstract

Background

Limited information exists on the prognostic impact of bleeding after percutaneous coronary intervention (PCI) in patients with chronic kidney disease (CKD). We investigated the impact of bleeding after PCI on the outcome of these patients.

Methods

The study included 2,934 patients with estimated creatinine clearance <60 ml/min. Bleeding events within 30 days after PCI were assessed using the Bleeding Academic Research Consortium (BARC) criteria. The primary outcome was 1-year mortality.

Results

Bleeding events occurred in 485 patients (16.5 %). BARC classes were: class 1 (n = 155), class 2 (n = 73), class 3a (n = 182), class 3b (n = 68), class 3c (n = 6) and class 4 (n = 1). There were 212 deaths over the first year after PCI: 60 deaths in patients who bled and 152 deaths in patients who did not bleed (Kaplan–Meier [KM] estimates, 12.5 and 6.3 %; odds ratio [OR] = 2.11, 95 % confidence interval [CI] 1.57–2.83, P < 0.001). Nonfatal myocardial infarction occurred in 71 patients who bled and in 141 patients who did not bleed (KM estimates, 14.8 and 5.8 %; OR = 2.70 [2.05–3.55], P < 0.001). After adjustment, bleeding was independently associated with increased risk of 1-year mortality (adjusted hazard ratio [HR] = 1.90 [1.33–2.72], P < 0.001) and myocardial infarction (adjusted HR = 2.74 [1.99–3.78], P < 0.001). Bleeding improved the discriminatory power of the multivariable model for prediction of mortality (absolute and relative integrated discrimination improvement [IDI], 0.011 and 15.4 %; P = 0.004) or myocardial infarction (absolute and relative IDI, 0.017 and 70.8 %; P < 0.001).

Conclusions

Peri-PCI bleeding in patients with CKD is independently associated with the increased risk of 1-year mortality and nonfatal myocardial infarction.

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References

  1. Coresh J, Selvin E, Stevens LA, Manzi J, Kusek JW, Eggers P, Van Lente F, Levey AS (2007) Prevalence of chronic kidney disease in the united states. JAMA 298:2038–2047

    Article  CAS  PubMed  Google Scholar 

  2. Latif F, Kleiman NS, Cohen DJ, Pencina MJ, Yen CH, Cutlip DE, Moliterno DJ, Nassif D, Lopez JJ, Saucedo JF (2009) Investigators E: In-hospital and 1-year outcomes among percutaneous coronary intervention patients with chronic kidney disease in the era of drug-eluting stents: A report from the event (evaluation of drug eluting stents and ischemic events) registry. JACC Cardiovasc Interv 2:37–45

    Article  PubMed  Google Scholar 

  3. Best PJ, Lennon R, Ting HH, Bell MR, Rihal CS, Holmes DR, Berger PB (2002) The impact of renal insufficiency on clinical outcomes in patients undergoing percutaneous coronary interventions. J Am Coll Cardiol 39:1113–1119

    Article  PubMed  Google Scholar 

  4. Gibson CM, Pinto DS, Murphy SA, Morrow DA, Hobbach HP, Wiviott SD, Giugliano RP, Cannon CP, Antman EM, Braunwald E (2003) Association of creatinine and creatinine clearance on presentation in acute myocardial infarction with subsequent mortality. J Am Coll Cardiol 42:1535–1543

    Article  CAS  PubMed  Google Scholar 

  5. Rubenstein MH, Harrell LC, Sheynberg BV, Schunkert H, Bazari H, Palacios IF (2000) Are patients with renal failure good candidates for percutaneous coronary revascularization in the new device era? Circulation 102:2966–2972

    Article  CAS  PubMed  Google Scholar 

  6. Ndrepepa G, Tada T, Fusaro M, Cassese S, King L, Hadamitzky M, Haase HU, Schomig A, Kastrati A, Pache J (2012) Association of coronary atherosclerotic burden with clinical presentation and prognosis in patients with stable and unstable coronary artery disease. Clin Res Cardiol 101:1003–1011

    Article  PubMed  Google Scholar 

  7. Zeymer U, Hochadel M, Hauptmann KE, Wiegand K, Schuhmacher B, Brachmann J, Gitt A, Zahn R (2013) Intra-aortic balloon pump in patients with acute myocardial infarction complicated by cardiogenic shock: Results of the alkk-pci registry. Clin Res Cardiol 102:223–227

    Article  PubMed  Google Scholar 

  8. Baber U, Gutierrez OM, Levitan EB, Warnock DG, Farkouh ME, Tonelli M, Safford MM, Muntner P (2013) Risk for recurrent coronary heart disease and all-cause mortality among individuals with chronic kidney disease compared with diabetes mellitus, metabolic syndrome, and cigarette smokers. Am Heart J 166:373–380

    Article  PubMed  Google Scholar 

  9. Attallah N, Yassine L, Fisher K, Yee J (2005) Risk of bleeding and restenosis among chronic kidney disease patients undergoing percutaneous coronary intervention. Clin Nephrol 64:412–418

    Article  CAS  PubMed  Google Scholar 

  10. Berger PB, Best PJ, Topol EJ, White J, DiBattiste PM, Chan AW, Kristensen SD, Herrmann HC, Moliterno DJ (2005) The relation of renal function to ischemic and bleeding outcomes with 2 different glycoprotein IIb/IIIa inhibitors: the do tirofiban and reopro give similar efficacy outcome (TARGET) trial. Am Heart J 149:869–875

    Article  CAS  PubMed  Google Scholar 

  11. Coca SG, Krumholz HM, Garg AX, Parikh CR (2006) Underrepresentation of renal disease in randomized controlled trials of cardiovascular disease. JAMA 296:1377–1384

    Article  CAS  PubMed  Google Scholar 

  12. Steinhubl SR, Kastrati A, Berger PB (2007) Variation in the definitions of bleeding in clinical trials of patients with acute coronary syndromes and undergoing percutaneous coronary interventions and its impact on the apparent safety of antithrombotic drugs. Am Heart J 154:3–11

    Article  CAS  PubMed  Google Scholar 

  13. Mehran R, Rao SV, Bhatt DL, Gibson CM, Caixeta A, Eikelboom J, Kaul S, Wiviott SD, Menon V, Nikolsky E, Serebruany V, Valgimigli M, Vranckx P, Taggart D, Sabik JF, Cutlip DE, Krucoff MW, Ohman EM, Steg PG, White H (2011) Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the bleeding academic research consortium. Circulation 123:2736–2747

    Article  PubMed  Google Scholar 

  14. Ndrepepa G, Schuster T, Hadamitzky M, Byrne RA, Mehilli J, Neumann FJ, Richardt G, Schulz S, Laugwitz KL, Massberg S, Schomig A, Kastrati A (2012) Validation of the bleeding academic research consortium definition of bleeding in patients with coronary artery disease undergoing percutaneous coronary intervention. Circulation 125:1424–1431

    Article  PubMed  Google Scholar 

  15. Kastrati A, Mehilli J, Schuhlen H, Dirschinger J, Dotzer F, ten Berg JM, Neumann FJ, Bollwein H, Volmer C, Gawaz M, Berger PB, Schomig A; Intracoronary Stenting and Antithrombotic Regimen-Rapid Early Action for Coronary Treatment Study Ivestigators (2004) A clinical trial of abciximab in elective percutaneous coronary intervention after pretreatment with clopidogrel. N Engl J Med 350:232–238

    Google Scholar 

  16. Mehilli J, Kastrati A, Schuhlen H, Dibra A, Dotzer F, von Beckerath N, Bollwein H, Pache J, Dirschinger J, Berger PP, Schomig A; Intracoronary Stenting and Antithrombotic Regimen: Is Abciximab a superior way to eliminate elevated thrombotic risk in diabetics study invesigators (2004) Randomized clinical trial of abciximab in diabetic patients undergoing elective percutaneous coronary interventions after treatment with a high loading dose of clopidogrel. Circulation 110:3627–3635

    Google Scholar 

  17. Hausleiter J, Kastrati A, Mehilli J, Schuhlen H, Pache J, Dotzer F, Glatthor C, Siebert S, Dirschinger J, Schomig A; ISAR-SMART-2 Investigators (2004) A randomized trial comparing phosphorylcholine-coated stenting with balloon angioplasty as well as abciximab with placebo for restenosis reduction in small coronary arteries. J Intern Med 256:388–397

    Google Scholar 

  18. Kastrati A, Mehilli J, Neumann FJ, Dotzer F, ten Berg J, Bollwein H, Graf I, Ibrahim M, Pache J, Seyfarth M, Schuhlen H, Dirschinger J, Berger PB, Schomig A; Intracoronary Stenting and Antithrombotic: Regimen Rapid Early Action for Coronary Treatment 2 (ISAR-REACT 2) Trial Investigators (2006) Abciximab in patients with acute coronary syndromes undergoing percutaneous coronary intervention after clopidogrel pretreatment: the ISAR-REACT 2 randomized trial. JAMA 295:1531–1538

    Google Scholar 

  19. Kastrati A, Neumann FJ, Mehilli J, Byrne RA, Iijima R, Buttner HJ, Khattab AA, Schulz S, Blankenship JC, Pache J, Minners J, Seyfarth M, Graf I, Skelding KA, Dirschinger J, Richardt G, Berger PB, Schomig A; ISAR-REACT 3 Trial Investigators (2008) Bivalirudin versus unfractionated heparin during percutaneous coronary intervention. N Engl J Med 359:688–696

    Google Scholar 

  20. Schulz S, Mehilli J, Neumann FJ, Schuster T, Massberg S, Valina C, Seyfarth M, Pache J, Laugwitz KL, Buttner HJ, Ndrepepa G, Schomig A, Kastrati A; Intracoronary Stenting and antithrombotic regimen: rapid early action for coronary treatment (ISAR-REACT 3A) trial investigators (2010) ISAR-REACT 3A: a study of reduced dose of unfractionated heparin in biomarker negative patients undergoing percutaneous coronary intervention. Eur Heart J 31:2482–2491

    Google Scholar 

  21. Kastrati A, Neumann FJ, Schulz S, Massberg S, Byrne RA, Ferenc M, Laugwitz KL, Pache J, Ott I, Hausleiter J, Seyfarth M, Gick M, Antoniucci D, Schomig A, Berger PB, Mehilli J; ISAR-REACT 4 Trial Investigators (2011) Abciximab and heparin versus bivalirudin for non-ST-elevation myocardial infarction. N Engl J Med 365:1980–1989

    Google Scholar 

  22. Pencina MJ, D’Agostino RB, D’Agostino RB, Vasan RS (2008) Evaluating the added predictive ability of a new marker: from area under the ROC curve to reclassification and beyond. Stat Med 27:157–17222

    Article  PubMed  Google Scholar 

  23. Kaya E, Cuneo A, Hochadel M, Junger C, Stepper W, Bramlage P, Kuck KH, Nienaber CA, Senges J, Eckardt L, Tebbe U, Reinecke H (2011) Impact of chronic kidney disease on the prognosis of patients undergoing percutaneous coronary interventions using drug-eluting stents. Clin Res Cardiol 100:1103–1109

    Article  PubMed  Google Scholar 

  24. Morel O, Muller C, Jesel L, Moulin B, Hannedouche T (2013) Impaired platelet p2y12 inhibition by thienopyridines in chronic kidney disease: mechanisms, clinical relevance and pharmacological options. Nephrol Dial Transpl 28:1994–2002

    Article  CAS  Google Scholar 

  25. Ndrepepa G, Berger PB, Mehilli J, Seyfarth M, Neumann FJ, Schomig A, Kastrati A (2008) Periprocedural bleeding and 1-year outcome after percutaneous coronary interventions: appropriateness of including bleeding as a component of a quadruple end point. J Am Coll Cardiol 51:690–697

    Article  PubMed  Google Scholar 

  26. Khaja A, Garg R, Govindarajan G, Madsen R, Aggarwal K (2008) Percutaneous coronary intervention and the use of glycoprotein IIb/IIIa inhibitors in patients with chronic kidney disease on dialysis: a single center experience. Hemodial Int 12(Suppl 2):S2–S8

    Article  PubMed  Google Scholar 

  27. Doyle BJ, Rihal CS, Gastineau DA, Holmes DR Jr (2009) Bleeding, blood transfusion, and increased mortality after percutaneous coronary intervention: implications for contemporary practice. J Am Coll Cardiol 53:2019–2027

    Article  PubMed  Google Scholar 

  28. Maluenda G, Mitulescu L, Ben-Dor I, A. Gaglia M J, Weissman G, Torguson R, L FS, Pichard AD, Bernardo NL, Waksman R (2012) Retroperitoneal hemorrhage after percutaneous coronary intervention in the current practice era: Clinical outcomes and prognostic value of abdominal/pelvic computed tomography. Catheter Cardiovasc Interv 80:29–36

  29. Nurko S (2006) Anemia in chronic kidney disease: causes, diagnosis, treatment. Cleve Clin J Med 73:289–297

    Article  PubMed  Google Scholar 

  30. Ndrepepa G, Neumann FJ, Richardt G, Schulz S, Tolg R, Stoyanov KM, Gick M, Ibrahim T, Fiedler KA, Berger PB, Laugwitz KL, Kastrati A (2013) Prognostic value of access and non-access sites bleeding after percutaneous coronary intervention. Circ Cardiovasc Interv 6:354–361

    Article  PubMed  Google Scholar 

  31. Pinkau T, Ndrepepa G, Kastrati A, Mann JF, Schulz S, Mehilli J, Schomig A (2008) Glycoprotein IIib/IIIa receptor inhibition with abciximab during percutaneous coronary interventions increases the risk of bleeding in patients with impaired renal function. Cardiology 111:247–253

    Article  CAS  PubMed  Google Scholar 

  32. White HD, Chew DP (2002) Bivalirudin: an anticoagulant for acute coronary syndromes and coronary interventions. Expert Opin Pharmacother 3:777–788

    Article  CAS  PubMed  Google Scholar 

  33. Saltzman AJ, Stone GW, Claessen BE, Narula A, Leon-Reyes S, Weisz G, Brodie B, Witzenbichler B, Guagliumi G, Kornowski R, Dudek D, Metzger DC, Lansky AJ, Nikolsky E, Dangas GD, Mehran R (2011) Long-term impact of chronic kidney disease in patients with st-segment elevation myocardial infarction treated with primary percutaneous coronary intervention: the horizons-ami (harmonizing outcomes with revascularization and stents in acute myocardial infarction) trial. JACC Cardiovasc Interv 4:1011–1019

    Article  PubMed  Google Scholar 

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Acknowledgments

The authors have no conflicts of interest to disclose.

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Authors and Affiliations

  1. Deutsches Herzzentrum, Lazarettstrasse 36, 80636, Munich, Germany

    Gjin Ndrepepa, Salvatore Cassese, Massimiliano Fusaro, Ilka Ott, Stefanie Schulz, Heribert Schunkert & Adnan Kastrati

  2. Universitäts-Herzzentrum Freiburg-Bad Krozingen, Bad Krozingen, Germany

    Franz-Josef Neumann

  3. 1.Medizinische Klinik rechts der Isar, Technische Universität, Munich, Germany

    Petra Hoppmann & Karl-Ludwig Laugwitz

  4. Herzzentrum der Segeberger Kliniken, Bad Segeberg, Germany

    Gert Richardt

  5. DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany

    Karl-Ludwig Laugwitz, Heribert Schunkert & Adnan Kastrati

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  1. Gjin Ndrepepa
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  2. Franz-Josef Neumann
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Correspondence to Gjin Ndrepepa.

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Ndrepepa, G., Neumann, FJ., Cassese, S. et al. Incidence and impact on prognosis of bleeding during percutaneous coronary interventions in patients with chronic kidney disease. Clin Res Cardiol 103, 49–56 (2014). https://doi.org/10.1007/s00392-013-0622-x

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  • DOI: https://doi.org/10.1007/s00392-013-0622-x

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