Periprocedural bleeding in patients undergoing percutaneous coronary intervention
- Paul Sorajja, MD
Paul Sorajja, MD
- Director, Center for Valve and Structural Heart Disease
- Minneapolis Heart Institute
- David R Holmes, Jr, MD
David R Holmes, Jr, MD
- Professor of Medicine
- Mayo Clinic College of Medicine
The advent of aggressive, multidrug antithrombotic therapy during percutaneous coronary intervention (PCI) has led to significant reductions in short- and long-term ischemic outcomes. (See "Antithrombotic therapy for elective percutaneous coronary intervention: General use".)
However, periprocedural bleeding is a frequent complication of PCI, and its frequency and severity is related in part to the intensity of antithrombotic therapy. Initially, periprocedural bleeding was viewed as a relatively benign consequence, but data have linked the occurrence of bleeding and its treatment (ie, blood transfusion) to increased short- and long-term mortality.
This topic reviews most aspects of periprocedural bleeding among patients undergoing PCI. Gastrointestinal bleeding in this setting is discussed separately. (See "Periprocedural and long-term gastrointestinal bleeding in patients undergoing percutaneous coronary intervention".)
Bleeding in relation to coronary artery bypass grafting or in association with diagnostic coronary angiography is discussed elsewhere. (See "Early noncardiac complications of coronary artery bypass graft surgery", section on 'Bleeding' and "Complications of diagnostic cardiac catheterization", section on 'Local vascular complications'.)
For the purpose of this topic, periprocedural bleeding is any bleeding that occurs during or within 48 hours of the procedure. However, some studies have including episodes of bleeding that occur during the index hospitalization. Estimates of the incidence of periprocedural bleeding during percutaneous coronary intervention (PCI) lack precision due to the use of different definitions. (See 'Incidence' below.) In addition, relevant data come from differing patient populations who were treated with varying regimens of adjunctive pharmacology. Early studies of adjunctive pharmacology in PCI utilized definitions that were extrapolated from fibrinolytic trials (such as the TIMI and GUSTO scales). These early definitions focused on occurrence of intracranial bleeds or large drops in hemoglobin . In more studies, the definitions of major bleeding have been more inclusive of less severe, but clinically significant, bleeds (table 1 and table 2). These definitions of major bleeding have included events such as the need for transfusion, bleeding requiring surgical intervention or prolonging hospital stay, or cardiac tamponade.
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- RISK FACTORS
- Antithrombotic therapy
- OUTCOMES AFTER BLEEDING
- Access site
- Gastrointestinal tract
- Activated clotting time
- Patients on oral anticoagulants
- CLINICAL MANIFESTATIONS AND DIAGNOSIS
- Femoral artery
- Retroperitoneal space
- Gastrointestinal tract
- Cranial bleeding
- Reversal of anticoagulation
- Reversal of GPIIb/IIIa inhibitors
- Blood transfusion
- - Potential mechanisms of adverse outcome after blood cell transfusion
- - Recommendations for blood transfusion
- SUMMARY AND RECOMMENDATIONS