Drug insight: bleeding after percutaneous coronary intervention-risks, measures and impact of anticoagulant treatment options.

In Europe, the use of interventional cardiology, including percutaneous coronary intervention (PCI), is increasing rapidly. The use of anticoagulation agents in PCI procedures is essential, but despite technical improvements, a significant associated bleeding risk still exists: more than 5% of patients are estimated to require transfusion, and around a further 13% experience minor bleeding. The methods used to detect and measure blood loss following PCI, however, vary widely between institutions and clinical trials. The risk of bleeding is influenced by therapeutic options and patient-specific characteristics, such as age, anemia and previous exposure to anticoagulants. Bleeding is associated with death, and also with less severe conditions such as thrombocytopenia, anemia, and hematoma, which have major impacts on patients' welfare and length of hospital stay, and on hospital budgets. Unfractionated heparin is the most widely used anticoagulant during PCI. Heparin, antiplatelet agents and other anticoagulants, however, have limitations that make it difficult to achieve a level of anticoagulation that prevents ischemic events without promoting bleeding. The use of low-molecular-weight heparin and the addition of glycoprotein IIb/IIIa inhibitors offer improved outcomes, but safer and more effective therapeutic agents are still required. New anticoagulants, including direct thrombin inhibitors such as bivalirudin, show similar levels of efficacy to heparin plus glycoprotein IIb/IIIa inhibitors, but with fewer hemorrhagic complications, and might advance clinical practice. This review evaluates the impact of PCI-related bleeding on patients' outcomes and hospital resources, examines methods for the detection and measurement of bleeding, and appraises the therapeutic options--particularly the newer agents--available to minimize hemorrhagic complications.