The use of vascular closure devices and the anticoagulant bivalirudin were associated with significantly lower bleeding rates following a percutaneous coronary intervention (PCI), which includes procedures such as balloon angioplasty or stent placement used to open narrowed coronary arteries. However, patients at greatest risk of bleeding, who would benefit most from these treatments, were least likely to receive them.

Percutaneous coronary intervention is performed approximately 1 million times a year in the United States. “Periprocedural bleeding is the most common non-cardiac complication of PCI and is associated with risk of early mortality as well as higher costs of care,” the authors were quoted as saying. They add that bleeding around the time of the procedure is modifiable through the use of bleeding avoidance strategies such as vascular closure devices and bivalirudin.

Steven P. Marso, M.D., of Saint Luke's Mid America Heart Institute in Kansas City, Mo., and colleagues analyzed bleeding rates after PCI procedures associated with the use of manual compression, vascular closure devices, bivalirudin, or vascular closure devices plus bivalirudin in patients across a spectrum of preprocedural bleeding risk. The analysis included data from 1,522,935 patients undergoing PCI procedures from January 2004 through September 2008.

“Overall, bleeding occurred in 30,429 patients, or about 2 percent. Manual compression was used in 35 percent of patients, vascular closure devices in 24 percent, bivalirudin in 23 percent, and vascular closure devices plus bivalirudin in 18 percent. Bleeding events were reported in 2.8 percent of patients who received manual compression, compared with 2.1 percent receiving vascular closure devices, 1.6 percent receiving bivalirudin, and 0.9 percent receiving both strategies,” according to the researchers.

“The results of this study suggest the need for additional research to better understand why higher-risk patients are least likely to receive bleeding avoidance strategies but also suggest the need to test interventions to overcome the risk-treatment paradox, such as enabling physicians to purposefully direct bleeding avoidance strategies to patients by providing preprocedural estimates of post-PCI bleeding,” wrote the authors.

SOURCE: Journal of the American Medical Association (JAMA), June 2, 2010