Abstract 4509: Individual Patient Risks of Major Bleeding and Myocardial Infarction and Their Implications for Mortality and for Treatment Choice in Acute Coronary Syndromes: Findings From the ACUITY Trial
Objectives: To develop prognostic models for risk of major bleed and risk of MI in patients (pts) with ACS to assess their subsequent impact on mortality, and to assess how alternative treatment strategies affect these risks in individual pts.
Methods: ACUITY trial randomized 13,819 ACS pts to heparin + GPIIb/IIIa (Hep+GPI), bivalirudin (Biv) + GPI, or Biv alone. Multivariate logistic regression models were developed relating independent baseline predictors to risk of non-CABG major bleed and of MI within 30 days. Time-updated covariate Cox models assessed how major bleeding and MIs impact on mortality risk up to 1 year.
Results: There were 9 independent predictors of major bleed (N=645, 4.7%), the strongest being female gender, planned PCI, anemia, age, and raised creatinine. Pts in the top 5th of bleeding risk score had 10x the risk of those in the bottom 5th. In the top 5th, the absolute risk of bleed was 13.8% on Hep+GPI and 6.7% on Biv. There were 5 independent predictors of MI (N=705, 5.1%), the strongest being planned CABG or planned PCI (vs medical treatment). Pts in the top 5th of MI risk score had 15x the risk of those in the bottom 5th. In the top 5th, the absolute risk of MI was 11.0% on Hep+GPI and 10.8% on Biv. The figures⇓ show the predicted risk of major bleeding and predicted risk of MI for all pts as if treated with Hep+GPI and Biv.
Conclusions: For individual pts with ACS there is an enormous identifiable variation in risks of major bleed and MI. For pts with a high risk of major bleed it is particularly important to use treatment modalities that will lower their bleeding risk, eg bivalirudin rather than heparin + GPI.