ACS: Bleeding Risk, Bleeding and Clinical Outcomes

Joaquin E. Cigarroa, MDClinical Chief of Cardiology

Clinical Professor of MedicineOHSU

Conflict of Interest

• I DO Not Have any relevant financial relationships to disclose.

• I will stay within evidence-based guidelines and away from commercial recommendations.

Clinical Case

• 76 year old woman admitted with intermittent chest discomfort

• Past Med Hx: diabetes, dyslipidemia, obesity, TIA

• Outpatient medications:Aspirin 81 mg dailySimvastatinMetforminGlipizide

• Physical exam:Vitals: 185 lbs, HR 92, BP 148/80Clear lungsCor: nonpalpable PMI, RRR, quiet S1 and S2,

no murmurs, normal JVPAbd: obeseExt: no edema, 1 plus pulses

ECG on Arrival

• Labs:troponin I 5.6HCT 32%Platelets 168,000Creat 1.4 (creat clearance of 30 ml/min)

Management Strategy

• What medical therapies?1. Antiplatelet:

a. Aspirinb. Clopidogrelc. Prasugreld. Ticagrelore. iv glycoprotein 2b/3a

inhibitor

• Antithrombotic therapies?1. Unfractionated Heparin2. Low molecular Heparin3. Fondaparinux4. Bivalirudin

What is Her Bleeding Risk

• 1. <2%

• 2. 2-5%

• 3. 5-10%

• 4. 11-15%

• 5. > 15%

Crusade Bleeding Variables

Patient Variable Points

Baseline Hct 0-9

Creatinine Clearance 0-39

Heart Rate 0-11

Female Gender 9

CHF 7

Diabetes Mellitus 6

Systolic Blood Pressure 1-10

Crusade Bleeding Score/Risk

Score Bleeding Risk

<20 3.1%

21-30 5.5%

31-40 8.6%

41-50 11.9%

>50 19.5%

Crusade Bleeding Score/Risk

Score Bleeding Risk

<20 3.1%

21-30 5.5%

31-40 8.6%

41-50 11.9%

>50 19.5%

Patient Score Patient Bleeding Risk

HCT 34 (3)CrCl 30 (35)HR 92 (6)Female (8)TIA (6)Diabetes (6)SBP 148 (1)

19.5%

Crusade

Crusade: In-Hospital Mortality

Interaction of Patient Variables, Medical Therapies and Procedural Variables

Pharmacology

• UFH

• Enoxaparin

• Fondaparinus

• Bivalirudin

• Aspirin

• Clopidogrel

• Prasugrel

• Ticagrelor

• IV 2b3a inhibitors

Procedure

• Access site

• Smaller sheaths

• Mechanical Closure Devices

• Minimize Bridging

• Minimize duration of antithrombotics

Patient Variables

• Calculate Risk Score

• What medical therapies would you recommend on this patient?

Acuity

Acuity

Acuity Major Bleeding

Oral Antiplatelet TherapiesPrimary Endpoint (CVD,MI,CVA)

Non CABG Major Bleed

ASA vs ASA/Clopidogrel 11.4% vs 9.3%* 1.34% vs 3.6%*

Clopidogrel/ASA vsPrasugrel/ASA

12.1% vs 9.9%* 1.8% vs 2.4%*

Prasugrel/ASA vsTicagrelor/ASA

11.7% vs 9.8%* 3.8% vs 4.5%*

* p<0.05

Early ACS: Impact of Early 2b/3a inhibitors in addition to Clopidogrel

Rival

Rival

Premier: Discharge Meds in AMI complicated by Bleeding

Clopidogrel and Omeprazole in CAD

NEJM 363;20

• Patients receiving dual antiplatelet tx were randomized to omeprazole or placebo.

• Primary endpoint: first occurrence of upper GI clinical events including:a. UGI bleedb. Confirmed ulcerc. Gastroduodenal erosions/obstructiond. Perforation

Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply.

Bhatt, D. L. et al. J Am Coll Cardiol 2008;52:1502-1517

Steps for Minimizing Gastrointestinal Bleeding

Clopidogrel vs ASA and Esomeprazole to Prevent Recurrent Ulcer Bleeding

NEJM 2005;353:238

• Patients on ASA for CV prevention, presented with ulcer bleeding and healed were randomized to clopidogrel vs ASA plus esomeprazole.

• 90% of patients had CAD or PAD

• Primary endpoint: recurrent bleeding during 12 months follow up.

Conclusion

• Patient risk of bleeding is important in selecting best therapies for treating ACS.

• Bleeding occurs more often in non access sites than access sites.

• Minimize dual antiplatelet therapy coupled with antithrombotic therapy.

• Minimize lovenox “bridging”.• Bleeding is associated with increase in ischemic

events and an increase in mortality.• Clinical decision making in this patient population

has become complex.