BLEEDING COMPLICATIONS AFTER ACUTE CORONARY SYNDROME
With Special Reference To Intracranial Hemorrhage Anna Graipe
Umeå University Medical Dissertations, New Series No 2107
Akademisk avhandling
som med vederbörligt tillstånd av Rektor vid Umeå universitet för avläggande av medicine doktorsexamen framläggs till offentligt försvar i
hörsalen Snäckan, Östersunds sjukhus fredagen den 19 februari 2021, kl. 09:00.
Avhandlingen kommer att försvaras på svenska.
Fakultetsopponent: Joakim Alfredsson, docent,
Medicinska fakulteten, Linköpings universitet, Linköping, Sverige.
Department of Public Healt and Clinical Medicine
Organization Document type Date of publication
Umeå University Doctoral thesis 29 January 2021
Department of Public Health and Clinical Medicine, Author
Anna Graipe Title
Bleeding Complications After Acute Coronary Syndrome With Special Reference To Intracranial Hemorrhage.
Abstract
Aims To assess the incidence, temporal trends, and factors associated with intracranial hemorrhage (ICH) after acute myocardial infarction (AMI); to investigate the impact on ICH risk of a change in treatment regimen from clopidogrel to ticagrelor; to estimate the risk of serious bleeding after acute coronary syndrome (ACS) and characterize the type of bleeding; and to identify factors associated with increased bleeding risk and assess if a serious bleeding is associated with increased mortality.
Method Patients with an AMI were identified using the Register of Information and Knowledge About Swedish Heart Intensive Care Admission (RIKS-HIA), and the data were amalgamated with the Swedish National Patient Register, 1998–2013, to identify ICH. The risk of ICH in the short and long terms was assessed, and time trends and risk factors were studied. The impact of the shift in treatment regimen from clopidogrel to ticagrelor was assessed. To avoid selection bias related to the choice of antiplatelet therapy, the study period was divided into two time cohorts, with the first prescription of ticagrelor in 2011 as a cutoff. To identify serious bleeding after ACS, data were obtained from the Nurse-Based Age-Independent Intervention to Limit Evolution of Disease After Acute Coronary Syndrome (or NAILED-ACS) risk factor trial, 2010–2014, and patients were followed until December 2017. Serious bleedings were identified in the local diagnosis registry, and medical records were scrutinized to validate all diagnoses.
Results The 30-day risk of ICH decreased during 1998 to 2008, from 0.2% to 0.1%. The decrease can be explained by a shift in reperfusion method from thrombolysis to percutaneous coronary intervention in patients with ST-elevation myocardial infarction. Age, hypertension, and previous hemorrhagic stroke were associated with increased risk. The cumulative incidence of ICH within one year of AMI was 0.35% and did not change during the 13-year follow-up (1998–2010) despite a considerable increase in the use of dual antiplatelet therapy. The incidence in the AMI cohort was twice that of a matched reference group. Age, decreased kidney function, and previous ischemic or hemorrhagic stroke were associated with an increased risk of ICH. Ticagrelor is a more potent P2Y12 inhibitor compared to clopidogrel and has previously been associated with increased bleeding risk;
however, ticagrelor was not associated with increased risk of ICH compared to clopidogrel in this study. In study IV, during a median follow-up of 4.6 years, 8.6% of ACS patients had a serious bleeding event after ACS, as did 13.4% of patients aged ≥75 years. The most common type was gastrointestinal, followed by ICH. Risk factors associated with serious bleeding were age ≥75 years, hypertension, and previous heart failure. Bleeding per se was not associated with increased mortality.
Conclusion The shift in reperfusion method likely explains the decrease in ICH in the acute phase after AMI. The incidence of ICH within one year after AMI was stable despite increased use of antithrombotic therapy and more potent P2Y12 inhibitors. Good clinical judgment and good risk factor control may have affected the results. Serious bleeding was relatively frequent in the long term after ACS, above all in the elderly, and recurrences were common. The gut was the most common bleeding site. Important risk factors for bleeding were age, hypertension, previous ischemic or hemorrhagic stroke, decreased renal function, and heart failure.
Keywords Acute myocardial infarction, acute coronary syndrome, bleeding, serious bleeding hemorrhage, intracranial hemorrhage, hemorrhagic stroke, intracerebral hemorrhage
Language ISBN ISSN Number of pages
English 978-91-7855-369-3 (print) 0346-6612 74 + 4 papers 978-91-7855-370-9 (pdf)
