Original title: Pre-Procedural Estimate of Individualized Bleeding Risk Impacts Physicians’ Utilization of Bivalirudin During Percutaneous Coronary Intervention. Reference: Seshu C. Rao et al. J Am Coll Cardiol 2013;61:1847–52

While safety of coronary angioplasty has improved over time, post-procedure bleeding  is still frequent with a large variability between centers. Bleeding is associated with increased mortality, myocardial infarction, stroke, increased hospital stay and higher costs. The risk score from the National Cardiovascular Data Registry (NCDR) can be used to classify patients into low (<1%), medium (1-3%) or high (3%) risk of bleeding according to 9 clinical variables pre-procedure. 

Bivalirudin has been shown to reduce bleeding complications and the benefit of this drug becomes greater the higher the risk of bleeding is.

This study included 6,491 patients who received coronary angioplasty between 2007 and 2011 comparing bleeding complications before and after 2009, when the NCDR bleeding risk score application was incorporated routinely. The use of bivalirudin increased globally from 26.9% to 34.2% (p <0.001) after risk scores began to apply. This was especially true for patients at intermediate risk (27% to 35%, p <0.001) and high (25% to 43%, p <0.001), however, its use declines for low-risk (30% 25%, p = 0.014). Post-procedure bleeding decreased after the prospective application of risk stratification. In low-risk patients the bleeding was similar both before and after application of the score (1.1% versus 1%, p = 0.976) nevertheless both in intermediate risk (3.4% versus 1.8%, p = 0.009) and high risk (6.9% versus 3.7%, p = 0.005) complications decreased significantly.

Conclusion:

The addition of an individualized risk of bleeding led to increased use of bivalirudin in patients with moderate and high risk and less use in low-risk. A concomitant  decrease in bleeding complications was observed in these patients.

Commentary:

Because the risk of bleeding is predictable and modifiable this is an ideal end point to observe the improvement in the daily practice of coronary angioplasty. Applying the score optimizes resources since the magnitude in reducing risk of bleeding depends on the initial patient. The article does not describe how many patients in this series received radial access, although it is expected that few did, since the bleeding edge in offering radial leaves little room for bivalirudin to show benefits. 

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