Department of Neurology, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China.; National Center for Neurological Disorders, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China.
Department of Cardiology, Cardiometabolic Medicine Center, Coronary Heart Disease Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Xicheng District, Beijing, China.; State Key Laboratory of Cardiovascular Disease, No.167 North Lishi Road, Xicheng District, Beijing, China.; National Clinical Research Center of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Xicheng District, Beijing, China.
Thromb Res. 2023 Sep;229:243-251. doi: 10.1016/j.thromres.2023.08.002. Epub 2023 Aug 6.
The association between bleeding and subsequent major adverse cardiac and cerebrovascular events (MACCE) remains poorly characterized. We aimed to evaluate the impact of hemorrhagic events in patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI).
A total of 1877 consecutive patients with AF and ACS or undergoing PCI were prospectively recruited. The primary endpoint was MACCE, including all-cause death, myocardial infarction, ischemic stroke, systemic embolism or ischemia-driven revascularization during follow-up. Post-discharge bleeding was graded according to TIMI criteria. Associations between bleeding and subsequent MACCE were examined using time-dependent multivariate Cox regression after adjusting for baseline covariates and the time from bleeding.
During a median follow-up of 34.2 months, 341 (18.2 %) had TIMI major or minor bleeding events, of whom 86 (25.2 %) also experienced MACCE. The risk of MACCE was significantly higher in patients with bleeding than those without (8.85 % versus 6.99 % per patient-year; HR, 1.568, 95 % CI, 1.232-1.994). In patients who had both bleeding and MACCE, 65.1 % (56 of 86) bleeding events occurred first. Temporal gradients in MACCE risk after major bleeding was highest within 30 days (HR, 23.877; 95 % CI, 12.810-44.506) and remained significant beyond 1 year (HR, 3.640; 95 % CI, 1.278-10.366). Minor bleeding was associated with increased risk of MACCE within 1 year.
In patients with AF and ACS or PCI, major and minor bleeding were associated with subsequent MACCE with time-dependency. Our findings may aid in better defining net clinical benefit of optimal antithrombotic therapy.
出血与随后发生的主要不良心脏和脑血管事件（MACCE）之间的关系仍未得到充分描述。我们旨在评估房颤（AF）和急性冠状动脉综合征（ACS）或经皮冠状动脉介入治疗（PCI）患者出血事件的影响。
共前瞻性招募了 1877 例连续的 AF 和 ACS 或 PCI 患者。主要终点是 MACCE，包括随访期间的全因死亡、心肌梗死、缺血性卒、全身性栓塞或缺血驱动的血运重建。根据 TIMI 标准对出院后出血进行分级。在调整基线协变量和出血后时间后，使用时间依赖性多变量 Cox 回归来检查出血与随后发生的 MACCE 之间的关系。
在中位随访 34.2 个月期间，341 例（18.2%）发生 TIMI 主要或次要出血事件，其中 86 例（25.2%）也发生了 MACCE。与无出血的患者相比，有出血的患者发生 MACCE 的风险明显更高（每患者年 8.85%与 6.99%；HR，1.568，95%CI，1.232-1.994）。在同时发生出血和 MACCE 的患者中，65.1%（86 例中的 56 例）出血事件先发生。大出血后 MACCE 风险的时间梯度在 30 天内最高（HR，23.877；95%CI，12.810-44.506），并且在 1 年后仍然显著（HR，3.640；95%CI，1.278-10.366）。在 1 年内，轻微出血与 MACCE 风险增加相关。
在 AF 和 ACS 或 PCI 患者中，主要和次要出血与随后的 MACCE 呈时间依赖性相关。我们的研究结果可能有助于更好地确定最佳抗血栓治疗的净临床获益。
