QJM Advance Access originally published online on July 29, 2008
QJM 2008 101(9):749-751; doi:10.1093/qjmed/hcn082
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Anaemia as predictor of gastrointestinal bleeding in atrial fibrillation patients undergoing percutaneous coronary artery stenting
Sir,We read with great interest the excellent review by Foley et al. who evaluate the risks of gastrointestinal bleeding in patients undergoing percutaneous coronary intervention (PCI) in relation to anti-platelet therapy.1 The authors emphasize the importance of several gastrointestinal bleeding major risk factors including use of dual anti-platelet therapy or non-steroidal anti-inflammatory drugs, increasing age, previous ulceration, helicobacter pylori infection, use of non-steroidal anti-inflammatory drugs and co-morbidity including sepsis and mechanical ventilation. However, they neither mention baseline anaemia nor triple antithrombotic drug use (aspirin, clopidogrel and warfarin) as conditions that could increase the rate of bleeding events after PCI-stenting.
In a recent analysis of a cohort of patients with atrial fibrillation (AF) undergoing PCI-stenting with additional indication for long-term oral anti-coagulation, we recently reported that triple antithrombotic use was the main predictor of late major bleeding (MB).2 Also, there are now some data that suggest anaemia as a high-risk marker for hemorrhagic complications in PCI-stenting.3 However, the impact of anaemia on the occurrence of MB and their clinical presentation in AF patients with an indication for oral anti-coagulation undergoing PCI-stenting has not been previously studied.
We studied 278 consecutive AF patients with indication for oral anti-coagulation who underwent PCI-stenting in two Spanish tertiary centres. Patients were classified as anaemic using the World Health Organization definition (Hb < 12.0 g/dl in women and <13.0 g/dl in men).4 During the follow-up (median 19.2 months [IQR 10.3–38.2]) patients were contacted by telephone to obtain the occurrence of MB.5
Baseline patient characteristics, as well as procedural variables, are shown in Table 1. Anaemia was presented in 114 (41%) patients. A total of 38 patients (14.4%) suffered MB over the study period. Overall, anaemic patients had higher rate of MB than non-anaemic patients (20.0% vs. 10.7%; p = 0.035). Gastrointestinal MB events (GI-MB) were more common amongst patients with baseline anaemia (12.4% vs. 3.1%; P = 0.004), whilst non-GI-MB were similar in both groups (7.7% vs. 7.5%; p = 0.958) (Fig. 1). The majority of MB occurred within first year of follow-up (63% at 6 months and 76% at 12 months of follow-up). Patients who had MB complications were more often taking triple anti-thrombotic therapy (57%). Almost all INR values on the day of MB were within the therapeutic range.
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Kaplan–Meier survival analysis of MB and GI-MB events at 2 years showed that anaemia was associated with lower event-free survival period (77% vs. 92%; log rank test, p = 0.006) and (89% vs. 98%; log rank test, p = 0.001), respectively (Fig. 2a and b).
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In Cox multivariate analyses, anaemia (HR 2.15, 95%CI 1.08–4.30; p = 0.030), previous stroke (HR 2.51, 95%CI 1.23–5.11; p = 0.012), triple antithrombotic therapy (HR 2.17, 95%CI 1.11–4.25; p = 0.024) and age (HR 1.05, 95%CI 1.002–1.009; p = 0.039) were independent predictors for MB; whereas anaemia (HR 4.73, 95%CI 1.53–14.61; p = 0.007), hypertension (HR 3.57, 95%CI 1.21–10.52; p = 0.021) and previous CABG (HR 4.81, 95%CI 1.08–21.36; p = 0.039) were independent predictors for GI-MB.
Thus, anaemia is a common comorbidity among AF patients with indication for oral anti-coagulation who undergo PCI-stenting, and strongly associated with increased MB complications. These findings emphasize the importance of a thorough search for predisposing bleeding sites and/or haemorrhagic diatheses.
Department of Cardiology, Hospital Universitario
Virgen de la Arrixaca, Murcia, Spain
Department of Cardiology, Hospital General
Universitario de Alicante, Spain
University Department of Medicine, City Hospital,
Birmingham (UK)
email: g.y.h.lip{at}bham.ac.uk
References
1. Foley P, Foley S, Kinnaird T, Anderson RA. Clinical review: gastrointestinal bleeding after percutaneous coronary intervention: a deadly combination. Q J Med (2008) 101:425–33.[Web of Science]
2. Manzano-Fernández S, Pastor FJ, Marín F, Cambronero F, Caro C, Pascual-Figal DA, et al. Increased major bleeding complications related to triple antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary artery stenting. In: Chest. (2008) (in press).
3. Nikolsky E, Aymong ED, Halkin A, Grines CL, Cox DA, Garcia E, et al. Impact of anaemia in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention: analysis from the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) Trial. J Am Coll Cardiol (2004) 44:547–53.
4. World Health Organization. Nutritional Anemias: Report of a WHO Scientific Group. (1968) Geneva: World Health Organization.
5. Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM-PLUS) study investigators. Inhibition of the platelet glycoprotein IIb/IIIa receptor with tirofiban in unstable angina and non-Q-wave myocardial infarction. N Engl J Med (1998) 338:1488–97.
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