C0316 - Severity of a Gastrointestinal Bleeding After Coronary Stenting Is Associated With a Subsequent Increased Risk of a Major Adverse Cardiovascular Event

Monday, October 24, 2022

3:00 PM – 5:00 PM ET

Location: Crown Ballroom

Presenting Author(s)

Pedro Cortes, MD

Mayo Clinic
Jacksonville, FL

Pedro Cortés, MD¹, Jennifer Zeng, BA¹, Christian Karime, MD², Maoyin Pang, MD, PhD²
¹Mayo Clinic, Jacksonville, FL; ²Mayo Clinic Florida, Jacksonville, FL

Introduction: Dual antiplatelet therapy following coronary stenting increases the risk of gastrointestinal bleeding (GIB). It remains unclear whether a GIB after coronary stenting is associated with major adverse cardiovascular events (MACE). We aimed to determine features of GIB that may predict the endpoint of MACE.

Methods: We performed a retrospective study of patients who had an index GIB following coronary stenting between January 2015 and June 2021 at a single academic center. Clinical data was collected retrospectively. Kaplan-Meier Estimates and Cox Proportional Hazards Regression Analysis were utilized to determine factors associated with a MACE following the index GIB. Statistical analysis was performed utilizing BlueSky Statistics software v. 7.0.

Results: 100 patients had GIB after coronary stenting and were included. Table 1. 32 had MACE following GIB (median time, 121 days, 26-234). MACE included acute coronary syndrome (6.3%), stroke (12.5%), heart failure exacerbation (46.9%), and need for revascularization (34.4%). At p < 0.10, labile INR, age > 65 years, and anticoagulation at time of initial coronary stenting were associated with a higher risk of MACE, whereas moderate alcohol use was associated with a reduced risk. 89 patients (89%) were on prescribed P2Y12 inhibitor at the time of index GIB, of which, 19 (21.3%) had it discontinued following GIB. The discontinuation of prescribed P2Y12 inhibitor was not associated with an increased risk of MACE. The absence of findings on endoscopy at GIB was weakly associated with an increased risk of MACE, p=0.0814. Being transferred to the ICU was the strongest predictor of MACE, p=0.0159, and a severe GIB (defined as requiring >/= 5 units of packed red blood cells [pRBCs], length of hospital stay >/= 7 days, transfer to ICU, cardiopulmonary arrest, or death) was weakly associated, p=0.0711. Figure 1. Number of pRBC transfused approached significance (HR=1.13 per 1 unit, 95% CI: 0.97-1.31, p=0.1081). The indication for the initial coronary stenting was not associated with the risk of MACE following GIB.

Discussion: In our single-center study, we found patients who were transferred to the ICU at the time of GIB, or had a severe bleed were subsequently at higher risk of MACE. This may be explained by the decreased oxygen carrying capacity at the time of GIB leading to a propensity to ischemia. Interestingly, however, the hemoglobin or drop in hemoglobin were not associated with MACE. Further studies are recommended.

Figure: Figure 1: Kaplan-Meier Estimates for A) Time to MACE after Initial GIB Following Coronary Stenting for All Patients, B) Time to MACE after Initial GIB Following Coronary Stenting by ICU Transfer Status at time of GIB, and C) Time to MACE after Initial GIB Following Coronary Stenting by Severity of GIB. Legend A: Red = All Patients; Legend B: Blue = Transferred to ICU at GI Bleed, Red = Not Transferred to ICU at GI Bleed; Legend C: Blue = Severe GIB, Red = Non-Severe GIB.

Baseline Characteristics Median (IQR) or Fraction (%)		Unadjusted Cox Regression For MACE after Index GIB
	All Patients N=100	HR (95% CI)	p-value
Age at Coronary Stent Placement, per 10 years	70.5 (61.7-77.8)	1.30 (0.93-1.84)	0.13
Male gender	74 (74.0%)	0.91 (0.42-1.99)	0.91
White Race	100 (100%)	NA	NA
Hispanic Ethnicity	1 (1.0%)	NA	NA
Never Smoker	32 (32.0%)	1.10 (0.53-2.30)	0.80
Body Mass Index, per 1 kg/m²	30.0 (26.4-30.4)	1.02 (0.97-1.07)	0.45
Obesity	50 (50.0%)	1.64 (0.80-3.39)	0.18
Comorbidities – defined as per HAS-BLED
Hypertension	91 (91.0%)	3.95 (0.53-29.09)	0.18
Chronic Kidney Disease	15 (15.0%)	1.49 (0.57-3.90)	0.42
Liver Disease	15 (15.0%)	1.78 (0.67-4.73)	0.25
History of stroke	12 (12.0%)	1.58 (0.60-4.14)	0.35
Prior Major Bleeding (before LHC)	28 (28.0%)	0.52 (0.20-1.36)	0.18
Labile INR	29 (29.0%)	2.00 (0.98-4.10)	0.0570
Age > 65	66 (66.0%)	2.43 (1.00-5.92)	0.0512
Medication predisposing to bleeding	100 (100.0%)	NA	NA
Alcohol use	26 (26.0%)	0.40 (0.14-1.14)	0.0868
HAS-BLED score	4 (3-5)	1.20 (0.92-1.55)	0.17
· HAS-BLED score > 3	53 (53.0%)
Coronary Catheterization Data
Pre-catheterization Endoscopy Performed	12 (12.0%)	0.85 (0.26-2.80)	0.79
· Delay in LHC due to endoscopy	1 (8.3%)	NA	NA
Indication for coronary catheterization
· Acute Coronary Syndrome	65 (65.0%)	1.64 (0.75-3.57)	0.21
o NSTEMI	41 (41.0%)	1.30 (0.64-2.63)	0.47
o STEMI	24 (24.0%)	1.33 (0.57-3.11)	0.51
· Stable CAD	35 (35.0%)	0.61 (0.28-1.33)	0.21
Number of Stents Placed, per 1 stent	2 (1-2)	1.19 (0.80-1.77)	0.39
· 3 or more stents placed	20 (20.0%0	1.14 (0.46-2.79)	0.78
Hemoglobin prior to catheterization, per 1 g/dL	12.70 (10.5-14.2)	0.88 (0.76-1.03)	0.11
Medications After Catheterization
Proton pump inhibitor	31 (31.0%)	1.30 (0.62-2.73)	0.48
SSRI	12 (12.0%)	1.61 (0.61-4.21)	0.33
NSAIDs	2 (2.0%)	NA	NA
Anticoagulation	42 (42.0%)	1.96 (0.96-4.00)	0.0652
· Warfarin	27 (27.0%)	1.50 (0.53-4.24)	0.45
· DOAC	14 (14.0%)	0.71 (0.25-2.02)	0.52
Indication for Anticoagulation
· Atrial Fibrillation	33 (33.0%)	1.24 (0.36-4.27)	0.74
· DVT/PE	6 (6.0%)	0.73 (0.17-3.19)	0.68
Gastrointestinal Bleed (GIB)	Patients with GIB N = 100
Median time to Index GIB from stenting, days	166 (22.8-374.8)	NA	NA
P2Y12 inhibitor taken prior to admission	89 (89.0%)	3.87 (0.53-28.4)	0.18
Presenting sign
· None	10 (10.0%)	1.98 (0.76-5.17)	0.16
· Hematemesis	11 (11.0%)	0.63 (0.15-2.66)	0.53
· Melena	50 (25.0%)	1.24 (0.61-2.53)	0.56
· Hematochezia	32 (32.0%)	0.62 (0.27-1.44)	0.26
Labs at time of GIB
· Hemoglobin, per 1 g/dL	8.4 (6.7-10.1)	0.92 (0.79-1.07)	0.28
o Hemoglobin drop, per 1 g/dL	3.8 (2.7-5.5)	0.97 (0.83-1.13)	0.65
· Platelets, per 50 x 10⁹/L	207 (167.8-272.8)	0.97 (0.81-1.17)	0.77
· INR, per 1 point	1.2 (1.1-1.9)	1.14 (0.94-1.37)	0.18
Endoscopy Performed	81 (81.0%)
· Inpatient Procedure	74/81 (91.4%)	0.44 (0.15-1.31)	0.14
· Normal endoscopy	9/81 (11.1%)	2.65 (0.89-7.93)	0.0814
· Esophageal varices	0	NA	NA
· Esophagitis	10/81 (12.4%)	0.47 (0.06-3.52)	0.46
· Gastritis	11/81 (13.6%)	1.80 (0.67-4.86)	0.25
· Ulcerations	33/81 (40.7%)	0.58 (0.24-1.42)	0.23
Source of Bleeding Found
· Unknown	26 (32.1%)	1.79 (0.78-4.09)	0.17
Intervention Performed	34/81 (42.0%)	0.69 (0.29-1.63)	0.40
Number of pRBCs transfused, per 1 unit	1 (0-3)	1.13 (0.97-1.31)	0.1081
Length of stay, per 1 day	3 (2-4)	1.02 (0.92-1.14)	1.02
Transfer to ICU during hospitalization	21 (21.0%)	2.62 (1.20-5.74)	0.0159
Death from GIB	1 (1.0%)	NA	NA
Severe GIB	26/100 (26.0%)	2.01 (0.94-4.28)	0.0711
P2Y12 Inhibitor Discontinued due to GIB	19/100 (19.0%)	0.66 (0.23-1.89)	0.44
Endpoint
Major Adverse Cardiovascular Event (MACE)	32/100 (32.0%)	NA	NA
· Median time to MACE, days	121.0 (25.8-233.8)	NA	NA
Type of MACE		NA	NA
· Acute Coronary Syndrome	2/32 (6.3%)	NA	NA
· Stroke or Transient Ischemic Attack	4/32 (12.5%)	NA	NA
· Hospitalization for Heart Failure	15 (46.9%)	NA	NA
· Need for revascularization	11 (34.4%)	NA	NA

Table: Table 1: Baseline Characteristics of All Patients with an Index GIB and Cox Proportional Hazard Regression Analysis for the Occurrence of MACE following Initial Coronary Stenting and Index GIB.

Disclosures:

Pedro Cortés indicated no relevant financial relationships.

Jennifer Zeng indicated no relevant financial relationships.

Christian Karime indicated no relevant financial relationships.

Maoyin Pang indicated no relevant financial relationships.

Pedro Cortés, MD¹, Jennifer Zeng, BA¹, Christian Karime, MD², Maoyin Pang, MD, PhD². C0316 - Severity of a Gastrointestinal Bleeding After Coronary Stenting Is Associated With a Subsequent Increased Risk of a Major Adverse Cardiovascular Event, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.