Predictors of major bleeding in acute coronary syndromes: the Global Registry of Acute Coronary Events (GRACE)

TLDR

No large multinational observational studies have identified predictors of major bleeding in acute coronary syndrome patients. The study aimed to develop a prediction rule to identify ACS patients at higher risk of major bleeding. Using logistic regression on 24,045 GRACE patients, the authors identified bleeding risk factors and built predictive models for the overall cohort and for STEMI, NSTEMI, and unstable angina subgroups. Major bleeding occurred in 3.9% of GRACE patients (4.8% STEMI, 4.7% NSTEMI, 2.3% unstable angina) and was independently predicted by older age, female sex, prior bleeding, and renal insufficiency; it also independently increased hospital mortality (OR 1.64).

Abstract

There have been no large observational studies attempting to identify predictors of major bleeding in patients with acute coronary syndromes (ACS), particularly from a multinational perspective. The objective of our study was thus to develop a prediction rule for the identification of patients with ACS at higher risk of major bleeding.Data from 24045 patients from the Global Registry of Acute Coronary Events (GRACE) were analysed. Factors associated with major bleeding were identified using logistic regression analysis. Predictive models were developed for the overall patient population and for subgroups of patients with ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina. The overall incidence of major bleeding was 3.9% (4.8% in patients with STEMI, 4.7% in patients with NSTEMI and 2.3% in patients with unstable angina). Advanced age, female sex, history of bleeding, and renal insufficiency were independently associated with a higher risk of bleeding (P<0.01). The association remained after adjustment for hospital therapies and performance of invasive procedures. After adjustment for a variety of potential confounders, major bleeding was significantly associated with an increased risk of hospital death (adjusted odds ratio 1.64, 95% confidence interval 1.18, 2.28).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. Simple baseline demographic and clinical characteristics identify patients at increased risk of major bleeding.