How to Minimize Bleeding in STEMI Patients Outline

How to Minimize Bleeding in STEMI Patients Outline: -Know about bleeding -Think about consequences of bleeding -Identify bleeding risk factors -Maximize risk : benefit Steven V. Manoukian, M. D. , F. A. C. C. , F. S. C. A. I. Vice President and Medical Director of Cardiovascular Services Hospital Corporation of America (HCA) Nashville, Tennessee Disclosures: COI-none, Off Label-yes

Steven V. Manoukian, MD I/we have no real or apparent conflicts of interest to report.

Rates of PCI Bleeding: NCDR 2010 -11 PCI Patients Without STEMI (n=787, 980) PCI Patients With STEMI (n=153, 268) Cath. PCI Bleeding: (1) occurring at percutaneous entry site, during or after cath lab visit until dc, may be external or hematoma >10 cm femoral, >5 cm brachial, or >2 cm radial; (2) retroperitoneal; (3) GI; (4) GU; and (5) other/unknown during or after cath lab visit until dc. All bleeding events required transfusion, prolonged stay, and/or drop in Hgb >3. 0 g/d. L. Dehmer GJ et al. JACC 2012.

Types of CCL Bleeding: NCDR 2010 -11 Dehmer GJ et al. JACC 2012.

Impact of Bleeding on Mortality (ACS) Manoukian SV, Feit F, Mehran R, et al. J Am Coll Cardiol 2007; 49: 1362 -8.

Severity of Bleeding and Impact on Mortality (R 2, ACUITY, HORIZONS) Mehran R et al. JACC INTV 2011.

Patient Risk Factors for Bleeding (ACS) Manoukian SV, Feit F, Mehran R, et al. J Am Coll Cardiol 2007; 49: 1362 -8.

Bleeding Risk Score (R 2, ACUITY, HORIZONS) Mehran R et al. JACC INTV 2011.

Bleeding Risk Score (R 2, ACUITY, HORIZONS) Mehran R et al. JACC INTV 2011.

Bleeding Risk Score (NCDR) Ahmed B and Dauerman HL. Circulation 2013.

PCI Anticoagulation Use 2010 -11 (NCDR) Dehmer GJ et al. JACC 2012.

HCA Anticoagulation Use: Abciximab, Eptifibatide, Tirofiban and Bivalirudin Percentage of Overall Dollars (Estimates) Abciximab 7% Bivalirudin 59% Eptifibatide 34% Tirofiban <1%

PCI Bleeding and Pharmacology in STEMI HORIZONS 30 -Day Endpoints Stone GW et al. NEJM 2008.

PCI Bleeding and Pharmacology Across Presentations 30 -Day: REPLACE-2, ACUITY-PCI, HORIZONS ITT STEMI ACS PCI Adapted from REPLACE-2, ACUITY-PCI, HORIZONS ITT.

Avoidance of Excess Pharmacology Dosing Alexander KP, et al. JAMA 2005; 294: 3108 -3116.

Avoidance of Excess Pharmacology Duration in PCI Shortened Course of Glycoprotein IIb/IIIa Inhibition BRIEF-PCI Trial Fung AY et al. JACC 2009.

Avoidance of Excess Pharmacology Duration in PCI Shortened Aggrastat vs. Integrilin in PCI SAVI-PCI Trial 600 patients undergoing elective or ACS PCI in approximately 20 U. S. centers Tirofiban Eptifibatide 1 -2 hour infusion 12 -18 hour infusion 25 mcg/kg + 0. 15 mcg/kg/min Standard Dosing Endpoints: Death, MI, UR or bleeding at discharge or 48 hours, whichever comes first. Hypothesis: Efficacy will be maintained with a 50 -75% reduction in bleeding and transfusion. Manoukian SV et al. http: //clinicaltrials. gov/ct 2/show/NCT 01522417? term=savi-pci&rank=1.

FABOLUS PRO: Prasugrel vs. Tirofiban in STEMI Valgimigli M et al. JACC INTV 2012.

Non-Pharmacologic Approaches to Bleeding: Access Site Utilization 2010 -11 (NCDR) Dehmer GJ et al. JACC 2012.

Non-Pharmacologic Approaches to Bleeding: r-PCI Success and Complication Rates Rao SV et al. JACC Intv 2008; 1: 379 -86.

Non-Pharmacologic Approaches to Bleeding: Vascular Closure Devices Major ASB = Hgb drop >3, RP bleed, ASB operation, hematoma >5 cm. Sanborn TA, Ebrahimi R, Manoukian SV et al. Circ Cardiovasc Interv 2010; 3: 57 -62.

Comprehensive Approaches to Bleeding: Individualized e. PRISM Informed Consents Courtesy, Spertus JA.

Conclusions • Know about bleeding – Rates increase with STEMI – Half are access site-related • Think about consequences of bleeding – Associated with mortality, adverse outcomes – Linked to cost, LOS, readmission • Identify bleeding risk factors – Especially age, sex, renal, anemia, presentation – Perform individualized baseline assessment • Do maximize risk : benefit – Pharmacologic: drug, dose, duration – Non-pharmacologic: site, size, VCD, IABP