Abstract 5764: Discharge Without Antiplatelet Therapy After Inhospital Bleeding is an Independent Predictor of 6-Month Mortality Among Patients With Acute Coronary Syndrome: A Pooled Analysis From PURSUIT, PARAGON-A, PARAGON-B and SYNERGY
Bleeding is an important complication of the management of acute coronary syndrome (ACS). Patients (pts) with bleeding are more likely to be discharged without antiplatelet therapy (AT); however, there are limited data on the impact of discharge without AT on longitudinal outcomes in this population.
Methods: We examined discharge AT (aspirin and/or thienopyridine) use among 8582 pts who experienced inhospital bleeding in 4 large trials of antithrombotic therapy in ACS. After adjusting for the propensity to receive AT, we compared 6-month outcomes among pts discharged with at least one antiplatelet drug vs. those discharged without AT.
Results: Almost 1 in 10 pts with bleeding were discharged without AT (n=826). These pts had more baseline comorbidities and were more likely to experience other inhospital non-fatal adverse events compared to patients discharged with AT. Adjusted outcomes associated with no AT vs. AT are shown in the Table⇓. In an interaction analysis, the effect of discharge without AT was worst among pts with more severe bleeding and those treated with PCI. In a treatment effect by treatment intensity analysis, the adjusted hazard ratio for death or myocardial infarction was 1.45 (95% Confidence interval(CI) 1.08–1.94) for pts receiving monotherapy and 1.90 (95% CI 1.27–2.84) for patients receiving no AT, compared to patients receiving dual AT.
Conclusions: Among patients with bleeding during ACS, discharge without antiplatelet therapy was associated with worse 6-month adverse outcomes. This effect was more pronounced among patients with more severe bleeding and among patients undergoing PCI. A gradient of better outcomes with greater AT intensity was observed. Thus, more research is required to determine the optimal approach to reinitiating AT among patients who bleed yet remain at high risk of recurrent ischemic events after discharge.