Prognostic value of access site and non-access site bleeding in ST-segment elevation myocardial infarction

Purpose: The aim of the current analysis was to investigate the relative prognostic value of access and non-access site bleeding on recurrent ischemic outcomes and mortality in patients with ST-segment elevation myocardial infarction (STEMI). Methods: The prognostic value of access and non-access site bleeding for one year cardiac and non cardiac mortality, reinfarction, stent thrombosis and stroke was investigated in 2002 STEMI patients undergoing primary PCI in a high volume tertiary center. Access site related bleeding was defined as a GUSTO severe or moderate bleeding originating at the PCI related arterial puncture site or in the retroperitoneal cavity. Hazard ratios for one year outcomes were calculated using Cox regression analyses, simultaneously including access and non-access site bleeding as time dependent covariates, adjusting for predictors of these outcomes in our dataset. We additionally performed a meta-analysis of adjusted hazard ratios of studies investigating the prognostic value of access- and non-access site bleedings using the generic inverse variance method (not shown). Results: Of the GUSTO severe or moderate bleedings within 30 days after PPCI, 52% was non-access site related and 63.2% was access-site related (some patients suffered both). After adjustment for relevant predictors, an access site bleeding was not associated with a higher risk of one year mortality (HR 1.03, p = 0.89), reinfarction (HR 1.16, p = 0.64), stent thrombosis (HR 0.55, p = 0.42) or stroke (HR 0.47, p = 0.31). Non-access site bleeding was associated with a higher risk of one year mortality (HR 2.77, p < 0.001), and stent thrombosis (HR 3.10 p = 0.021), but not of reinfarction (HR 1.46, p = 0.24) and stroke (no patients with non-access site bleeding suffered a stroke). Non-access site bleedings were associated with higher rates of premature discontinuation of antiplatelet therapy (clopidogrel 8.5 vs 1.7%, p=0.019, aspirin or clopidogrel 15.7 vs 4.8%, p=0.006). Conclusion: Access site related bleeding was not associated with an increased risk of mortality and recurrent ischemic events, while bleedings occurring at non-access sites were associated with higher rates of premature cessation of antiplatelet therapy, increased risk of mortality and stent thrombosis.