Impact of anaemia, bleeding, and transfusions in acute coronary syndromes: a shift in the paradigm
TLDR
A four- to five-fold increase in the risk of death, MI, and stroke at 30 days has been observed in patients with bleeding events, as compared to those without, both in the short- and long-term.Abstract:
Over the last two decades, major improvements in clinical outcome have been achieved in the management of acute coronary syndromes (ACS), with or without ST-segment elevation. In both these clinical settings, the pharmacological approach comprising anti-platelet agents, (or a combination thereof), anticoagulants, thrombolytic treatment in case of ST-elevation MI (STEMI) combined with mechanical or surgical revascularization or reperfusion, has led to a dramatic reduction in the rate of ischaemic events, namely death, death/myocardial infarction (MI), or death/MI/stroke. However, this has been achieved at the cost of a higher risk of bleeding complications, which were considered, until recently, to be inherent to ACS management, and to be a side effect devoid of serious clinical implications, except for intra-cranial bleeding. Bleeding complications were thought to be the price to pay for the improvement in the risk of ischaemic events, and were considered to be easily controlled, particularly thanks to a liberal transfusion policy. In this context, the risk factors for bleeding have been identified, and include baseline characteristics, such as age, female gender, renal failure, diabetes, and heart failure. In addition, the number and dosage of anti-thrombotic drugs, the use of fibrinolytic treatments, and the use of invasive strategies, required to achieve mechanical reperfusion or revascularization, also play an important role.1,2
However, over the last 5 years, it has become clear that bleeding complications occurring during the initial phase of ACS have a considerable impact on prognosis, especially in terms of death, MI, and stroke, both in the short- and long-term. A four- to five-fold increase in the risk of death, MI, and stroke at 30 days has been observed in patients with bleeding events, as compared to those without.2–4
The potential mechanisms by which …
Corresponding author. Tel: +33 381 668 539; fax: +33 381 668 582. E-mail address : jpbassan{at}univ-fcomte.frread more
Citations
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Ticagrelor versus Clopidogrel in Patients with Acute Coronary Syndromes
Lars Wallentin,Richard C. Becker,Andrzej Budaj,Christopher P. Cannon,Håkan Emanuelsson,Claes Held,Jay Horrow,Steen Husted,Stefan James,Hugo A. Katus,Kenneth W. Mahaffey,Benjamin M. Scirica,Allan M. Skene,Philippe Gabriel Steg,Robert F. Storey,Robert A. Harrington +15 more
TL;DR: In patients who have an acute coronary syndrome with or without ST-segment elevation, treatment with ticagrelor as compared with clopidogrel significantly reduced the rate of death from vascular causes, myocardial infarction, or stroke without an increase in the rates of overall major bleeding but with an increase of non-procedure-related bleeding.
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Early diagnosis of myocardial infarction with sensitive cardiac troponin assays.
Tobias Reichlin,Willibald Hochholzer,Stefano Bassetti,Stefano Bassetti,Stephan Steuer,Claudia Stelzig,Sabine Hartwiger,Stefan Biedert,Nora Schaub,Christine Buerge,Mihael Potocki,Markus Noveanu,Tobias Breidthardt,Raphael Twerenbold,Katrin Winkler,Roland Bingisser,Christian Mueller +16 more
TL;DR: The diagnostic performance of sensitive cardiac troponin assays is excellent, and these assays can substantially improve the early diagnosis of acute myocardial infarction, particularly in patients with a recent onset of chest pain.
Journal ArticleDOI
Apixaban with Antiplatelet Therapy after Acute Coronary Syndrome
John H. Alexander,Renato D. Lopes,Stefan James,Rakhi Kilaru,Yaohua He,Puneet Mohan,Deepak L. Bhatt,Shaun G. Goodman,Freek W.A. Verheugt,Marcus Flather,Kurt Huber,Danny Liaw,Steen Elkjær Husted,Jose Lopez-Sendon,Raffaele De Caterina,Petr Jansky,Harald Darius,Dragos Vinereanu,Jan H. Cornel,Frank Cools,Dan Atar,Jose L. Leiva-Pons,Matyas Keltai,Hisao Ogawa,Prem Pais,Alexander Parkhomenko,Witold Rużyłło,Rafael Diaz,Harvey D. White,Mikhail Ruda,Margarida Geraldes,Jack Lawrence,Robert A. Harrington,Lars Wallentin +33 more
TL;DR: The addition of apixaban, at a dose of 5 mg twice daily, to antiplatelet therapy in high-risk patients after an acute coronary syndrome increased the number of major bleeding events without a significant reduction in recurrent ischemic events as mentioned in this paper.
Journal ArticleDOI
Early versus Delayed Invasive Intervention in Acute Coronary Syndromes
Shamir R. Mehta,Christopher B. Granger,William E. Boden,Philippe Gabriel Steg,Jean-Pierre Bassand,David P. Faxon,Rizwan Afzal,Susan Chrolavicius,Sanjit S. Jolly,Petr Widimsky,Alvaro Avezum,Hans-Jürgen Rupprecht,Jun Zhu,Jacques Col,Madhu K. Natarajan,Craig Horsman,Keith A.A. Fox,Salim Yusuf +17 more
TL;DR: Early intervention did not differ greatly from delayed intervention in preventing the primary outcome, but it did reduce the rate of the composite secondary outcome of death, myocardial infarction, or refractory ischemia and was superior to delayed Intervention in high-risk patients.
Journal ArticleDOI
Dose comparisons of clopidogrel and aspirin in acute coronary syndromes.
Rajendra H. Mehta,Jean-Pierre Bassand,Rafael Diaz,Estudios Clinicos Latinoamérica,John W. Eikelboom,Christopher B. Granger,Sanjit S. Jolly,McMaster Univer,Campbell D. Joyner,Rizwan Afzal,Salim Yusuf +10 more
TL;DR: In patients with an acute coronary syndrome who were referred for an invasive strategy, there was no significant difference between a 7-day, double-dose clopidogrel regimen and the standard-dose regimen, or between higher- dose aspirin and lower-dose aspirin, with respect to the primary outcome of cardiovascular death, myocardial infarction, or stroke.
References
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Journal ArticleDOI
Adverse Impact of Bleeding on Prognosis in Patients With Acute Coronary Syndromes
TL;DR: In ACS patients without persistent ST-segment elevation, there is a strong, consistent, temporal, and dose-related association between bleeding and death, and a similar association was evident between major bleeding and ischemic events, including myocardial infarction and stroke.
Journal ArticleDOI
Comparison of fondaparinux and enoxaparin in acute coronary syndromes.
Salim Yusuf,Shamir R. Mehta,Susan Chrolavicius,Rizwan Afzal,Janice Pogue,Christopher B. Granger,Andrzej Budaj,Ron J.G. Peters,Jean-Pierre Bassand,Lars Wallentin,Campbell D. Joyner,Keith A.A. Fox +11 more
TL;DR: Fondaparinux is similar to enoxaparin in reducing the risk of ischemic events at nine days, but it substantially reduces major bleeding and improves long term mortality and morbidity.
Journal ArticleDOI
Blood flow regulation by S-nitrosohemoglobin in the physiological oxygen gradient
Jonathan S. Stamler,Li Jia,Jerry P. Eu,Timothy J. McMahon,Ivan T. Demchenko,Joseph Bonaventura,Kim Gernert,Claude A. Piantadosi +7 more
TL;DR: By sensing the physiological oxygen gradient in tissues, hemoglobin exploits conformation-associated changes in the position of cysteinebeta93 SNO to bring local blood flow into line with oxygen requirements.
Journal ArticleDOI
Relationship of blood transfusion and clinical outcomes in patients with acute coronary syndromes.
Sunil V. Rao,James G. Jollis,Robert A. Harrington,Christopher B. Granger,L. Kristin Newby,Paul W. Armstrong,David J. Moliterno,Lauren Lindblad,Karen S. Pieper,Eric J. Topol,Jonathan S. Stamler,Robert M. Califf +11 more
TL;DR: Blood transfusion in the setting of acute coronary syndromes is associated with higher mortality, and this relationship persists after adjustment for other predictive factors and timing of events.
Journal ArticleDOI
Predictors of major bleeding in acute coronary syndromes: the Global Registry of Acute Coronary Events (GRACE)
Mauro Moscucci,Keith A.A. Fox,Christopher P. Cannon,Werner Klein,Jose Lopez-Sendon,Gilles Montalescot,Kami White,Robert J. Goldberg +7 more
TL;DR: 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 and it was significantly associated with an increased risk of hospital death.
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