Association between arterial access site and anticoagulation strategy on major bleeding and mortality: A historical cohort analysis in the Veteran population

Jayant Bagai, Bert Little, Subhash Banerjee

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2 Citations (Scopus)

Abstract

Background: Studies have shown reduction in major bleeding with trans-radial intervention (TRI) compared with trans-femoral intervention (TFI), and with use of bivalirudin compared with heparin + glycoprotein IIb/IIIa inhibitors (GPI). We compared major bleeding, mortality and the interaction between arterial access site and the anticoagulant used for PCI in Veterans. Methods: A retrospective cohort of 1192 consecutive patients who underwent PCI at a VA hospital between 2006 and 2012 was divided into TFI-heparin (n = 192), TFI-bivalirudin (n = 272), TRI-heparin (n = 274) and TRI-bivalirudin (n = 454) groups. Primary outcomes were in-hospital major bleeding, in-hospital and 1-year all-cause mortality. Secondary outcomes were in-hospital MI, in-hospital and 1-year MACE and net adverse cardiovascular events (NACE - composite of major bleeding + MACE). Results: Femoral access was associated with a significantly increased risk of major bleeding compared with radial access (OR 11.87, p. <. 0.001). Correspondingly, radial access was protective against major bleeding compared with femoral access (OR 0.128, p. <. 0.01), but did not lower mortality or MACE by itself. Severe anemia was the only predictor of in-hospital all-cause mortality (OR = 27.62, p. <. 0.008). Presence of anemia and age. >. 70 predicted 1-year mortality, whereas major bleeding and anemia predicted 1-year MACE. An interaction was noted between anticoagulant and access site, such that heparin showed significantly greater major bleeding in the femoral group compared with the radial group. Bivalirudin resulted in similar risk of bleeding, regardless of access site. There was a synergistic interaction between radial access and heparin (HR 0.38, p. <. 0.05), but not radial access and bivalirudin, on reduction in 1-year NACE. Conclusion: Radial access for PCI is associated with reduction in major bleeding, but does not have an effect on in-patient or 1-year MACE and mortality. Major bleeding is associated with poor short and intermediate term outcomes. In addition, anemia is strongly associated with increased in-patient and 1-year mortality. There is a differential effect of heparin but not bivalirudin on major bleeding, depending on the access site. There is no synergism between radial access and bivalirudin in lowering the composite outcome of MACE and major bleeding at 1. year.

Original languageEnglish (US)
JournalCardiovascular Revascularization Medicine
DOIs
StateAccepted/In press - Apr 10 2017

Fingerprint

Veterans
Cohort Studies
Hemorrhage
Mortality
Population
Heparin
Thigh
Anticoagulants
Anemia
Platelet Glycoprotein GPIIb-IIIa Complex
bivalirudin

Keywords

  • Bivalirudin
  • Heparin
  • Trans-femoral PCI
  • Trans-radial PCI

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

@article{c85d6433076b4b9bb14e5415b940e4c2,
title = "Association between arterial access site and anticoagulation strategy on major bleeding and mortality: A historical cohort analysis in the Veteran population",
abstract = "Background: Studies have shown reduction in major bleeding with trans-radial intervention (TRI) compared with trans-femoral intervention (TFI), and with use of bivalirudin compared with heparin + glycoprotein IIb/IIIa inhibitors (GPI). We compared major bleeding, mortality and the interaction between arterial access site and the anticoagulant used for PCI in Veterans. Methods: A retrospective cohort of 1192 consecutive patients who underwent PCI at a VA hospital between 2006 and 2012 was divided into TFI-heparin (n = 192), TFI-bivalirudin (n = 272), TRI-heparin (n = 274) and TRI-bivalirudin (n = 454) groups. Primary outcomes were in-hospital major bleeding, in-hospital and 1-year all-cause mortality. Secondary outcomes were in-hospital MI, in-hospital and 1-year MACE and net adverse cardiovascular events (NACE - composite of major bleeding + MACE). Results: Femoral access was associated with a significantly increased risk of major bleeding compared with radial access (OR 11.87, p. <. 0.001). Correspondingly, radial access was protective against major bleeding compared with femoral access (OR 0.128, p. <. 0.01), but did not lower mortality or MACE by itself. Severe anemia was the only predictor of in-hospital all-cause mortality (OR = 27.62, p. <. 0.008). Presence of anemia and age. >. 70 predicted 1-year mortality, whereas major bleeding and anemia predicted 1-year MACE. An interaction was noted between anticoagulant and access site, such that heparin showed significantly greater major bleeding in the femoral group compared with the radial group. Bivalirudin resulted in similar risk of bleeding, regardless of access site. There was a synergistic interaction between radial access and heparin (HR 0.38, p. <. 0.05), but not radial access and bivalirudin, on reduction in 1-year NACE. Conclusion: Radial access for PCI is associated with reduction in major bleeding, but does not have an effect on in-patient or 1-year MACE and mortality. Major bleeding is associated with poor short and intermediate term outcomes. In addition, anemia is strongly associated with increased in-patient and 1-year mortality. There is a differential effect of heparin but not bivalirudin on major bleeding, depending on the access site. There is no synergism between radial access and bivalirudin in lowering the composite outcome of MACE and major bleeding at 1. year.",
keywords = "Bivalirudin, Heparin, Trans-femoral PCI, Trans-radial PCI",
author = "Jayant Bagai and Bert Little and Subhash Banerjee",
year = "2017",
month = "4",
day = "10",
doi = "10.1016/j.carrev.2017.06.005",
language = "English (US)",
journal = "Cardiovascular Revascularization Medicine",
issn = "1553-8389",
publisher = "Elsevier Inc.",

}

TY - JOUR

T1 - Association between arterial access site and anticoagulation strategy on major bleeding and mortality

T2 - A historical cohort analysis in the Veteran population

AU - Bagai, Jayant

AU - Little, Bert

AU - Banerjee, Subhash

PY - 2017/4/10

Y1 - 2017/4/10

N2 - Background: Studies have shown reduction in major bleeding with trans-radial intervention (TRI) compared with trans-femoral intervention (TFI), and with use of bivalirudin compared with heparin + glycoprotein IIb/IIIa inhibitors (GPI). We compared major bleeding, mortality and the interaction between arterial access site and the anticoagulant used for PCI in Veterans. Methods: A retrospective cohort of 1192 consecutive patients who underwent PCI at a VA hospital between 2006 and 2012 was divided into TFI-heparin (n = 192), TFI-bivalirudin (n = 272), TRI-heparin (n = 274) and TRI-bivalirudin (n = 454) groups. Primary outcomes were in-hospital major bleeding, in-hospital and 1-year all-cause mortality. Secondary outcomes were in-hospital MI, in-hospital and 1-year MACE and net adverse cardiovascular events (NACE - composite of major bleeding + MACE). Results: Femoral access was associated with a significantly increased risk of major bleeding compared with radial access (OR 11.87, p. <. 0.001). Correspondingly, radial access was protective against major bleeding compared with femoral access (OR 0.128, p. <. 0.01), but did not lower mortality or MACE by itself. Severe anemia was the only predictor of in-hospital all-cause mortality (OR = 27.62, p. <. 0.008). Presence of anemia and age. >. 70 predicted 1-year mortality, whereas major bleeding and anemia predicted 1-year MACE. An interaction was noted between anticoagulant and access site, such that heparin showed significantly greater major bleeding in the femoral group compared with the radial group. Bivalirudin resulted in similar risk of bleeding, regardless of access site. There was a synergistic interaction between radial access and heparin (HR 0.38, p. <. 0.05), but not radial access and bivalirudin, on reduction in 1-year NACE. Conclusion: Radial access for PCI is associated with reduction in major bleeding, but does not have an effect on in-patient or 1-year MACE and mortality. Major bleeding is associated with poor short and intermediate term outcomes. In addition, anemia is strongly associated with increased in-patient and 1-year mortality. There is a differential effect of heparin but not bivalirudin on major bleeding, depending on the access site. There is no synergism between radial access and bivalirudin in lowering the composite outcome of MACE and major bleeding at 1. year.

AB - Background: Studies have shown reduction in major bleeding with trans-radial intervention (TRI) compared with trans-femoral intervention (TFI), and with use of bivalirudin compared with heparin + glycoprotein IIb/IIIa inhibitors (GPI). We compared major bleeding, mortality and the interaction between arterial access site and the anticoagulant used for PCI in Veterans. Methods: A retrospective cohort of 1192 consecutive patients who underwent PCI at a VA hospital between 2006 and 2012 was divided into TFI-heparin (n = 192), TFI-bivalirudin (n = 272), TRI-heparin (n = 274) and TRI-bivalirudin (n = 454) groups. Primary outcomes were in-hospital major bleeding, in-hospital and 1-year all-cause mortality. Secondary outcomes were in-hospital MI, in-hospital and 1-year MACE and net adverse cardiovascular events (NACE - composite of major bleeding + MACE). Results: Femoral access was associated with a significantly increased risk of major bleeding compared with radial access (OR 11.87, p. <. 0.001). Correspondingly, radial access was protective against major bleeding compared with femoral access (OR 0.128, p. <. 0.01), but did not lower mortality or MACE by itself. Severe anemia was the only predictor of in-hospital all-cause mortality (OR = 27.62, p. <. 0.008). Presence of anemia and age. >. 70 predicted 1-year mortality, whereas major bleeding and anemia predicted 1-year MACE. An interaction was noted between anticoagulant and access site, such that heparin showed significantly greater major bleeding in the femoral group compared with the radial group. Bivalirudin resulted in similar risk of bleeding, regardless of access site. There was a synergistic interaction between radial access and heparin (HR 0.38, p. <. 0.05), but not radial access and bivalirudin, on reduction in 1-year NACE. Conclusion: Radial access for PCI is associated with reduction in major bleeding, but does not have an effect on in-patient or 1-year MACE and mortality. Major bleeding is associated with poor short and intermediate term outcomes. In addition, anemia is strongly associated with increased in-patient and 1-year mortality. There is a differential effect of heparin but not bivalirudin on major bleeding, depending on the access site. There is no synergism between radial access and bivalirudin in lowering the composite outcome of MACE and major bleeding at 1. year.

KW - Bivalirudin

KW - Heparin

KW - Trans-femoral PCI

KW - Trans-radial PCI

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U2 - 10.1016/j.carrev.2017.06.005

DO - 10.1016/j.carrev.2017.06.005

M3 - Article

C2 - 28624360

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JO - Cardiovascular Revascularization Medicine

JF - Cardiovascular Revascularization Medicine

SN - 1553-8389

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