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Cortés P, Zeng JJ, Karime C, Lewis MD, Gharacholou SM, Antwi SO, Pang M. Validation of prediction tools for GI bleeding in patients on dual anti-platelet therapy after percutaneous coronary intervention. Gastrointest Endosc 2024; 99:10-20.e6. [PMID: 37579980 DOI: 10.1016/j.gie.2023.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/07/2023] [Accepted: 08/04/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND AND AIMS The management of dual anti-platelet therapy after percutaneous coronary intervention (PCI) and GI bleeding (GIB) remains a clinical dilemma. We sought to identify predictors of GIB and recurrent bleeding and to determine whether recurrent bleeding increases the risk of major adverse cardiovascular events (MACEs). METHODS In this single-center retrospective study, patients undergoing PCI were identified. The primary and secondary endpoints were GIB at 180 days and recurrent bleeding or MACE at 365 days. Logistic regression was used to identify predictors of GIB and recurrent bleeding. Cox proportional hazards modeling was used to determine whether recurrent bleeding can predict a MACE. RESULTS Five hundred thirty-six patients were included. On multivariable analysis, PCI for acute coronary syndrome was associated with a 95% increased odds of GIB (P < .001). The P2Y12 inhibitor was continued in >90% of patients, which trended toward significance for recurrent bleeding (P < .10). The HAS-BLED score (Hypertension, Abnormal renal and liver function, Stroke, Bleeding tendency or predisposition, Labile INRs, Elderly, Drugs), including a labile international normalized ratio and prior major bleeding, was strongly associated with recurrent bleeding (P ≤ .009). Recurrent bleeding was associated with a 115% increased risk of MACEs (P = .02). We derived a novel risk score, named the SIGE score ([S]TEMI at PCI, having a labile [I]NR at PCI, index [G]IB within 180 days of PCI, and previous precatheterization [E]ndoscopy within 6 months), to predict recurrent bleeding at 365 days with a high predictive accuracy (area under the curve, .773; 95% confidence interval, .702-.845). CONCLUSIONS The SIGE score may help to predict recurrent bleeding, which was shown to be associated with an increased risk of MACEs. Further external validation is needed.
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Affiliation(s)
- Pedro Cortés
- Division of Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Jennifer J Zeng
- Krieger School of Arts & Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Christian Karime
- Division of Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Michele D Lewis
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Samuel O Antwi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA; Division of Epidemiology, Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, Florida, USA
| | - Maoyin Pang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
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Yoo AY, Joo MK, Park JJ, Lee BJ, Kim SH, Kim WS, Chun HJ. Recurrent Non-Variceal Upper Gastrointestinal Bleeding among Patients Receiving Dual Antiplatelet Therapy. Diagnostics (Basel) 2023; 13:3444. [PMID: 37998579 PMCID: PMC10670490 DOI: 10.3390/diagnostics13223444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/29/2023] [Accepted: 11/13/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Patients undergoing dual antiplatelet therapy (DAPT) may experience recurrent gastrointestinal bleeding (GIB). We investigated the clinical characteristics and risk factors for recurrent non-variceal upper gastrointestinal bleeding (NVUGIB) in patients who had experienced NVUGIB while receiving DAPT. METHODS We enrolled patients diagnosed with NVUGIB while receiving DAPT between 2006 and 2020. Definite bleeding was confirmed by esophagogastroduodenoscopy in all NVUGIB patients. RESULTS A total of 124 patients were diagnosed with NVUGIB while receiving DAPT. They were predominantly male (n = 103, 83.1%), bleeding mostly from the stomach (n = 94, 75.8%) and had peptic ulcers (n = 72, 58.1%). After the successful hemostasis of NVUGIB, 36 patients (29.0%) experienced at least one episode of recurrent upper GIB, 19 patients (15.3%) died, and 7 (5.6%) patients had a bleeding-related death. Multivariate analysis showed that age was a significant factor for re-bleeding (odds ratio [OR], 1.050; 95% confidence interval [CI]: 1.001-1.102; p-value: 0.047), all-cause mortality (OR, 1.096; 95% CI: 1.020-1.178, p = 0.013), and re-bleeding-related mortality (OR, 1.187; 95% CI: 1.032-1.364, p-value: 0.016). In Kaplan-Meier analysis, the cumulative probabilities of re-bleeding, death, and bleeding-related death were significantly higher in patients aged 70 and older (p = 0.008, <0.001, and 0.009, respectively). CONCLUSIONS Clinicians should be cautious about re-bleeding and mortality in elderly patients who experience NVUGIB while receiving DAPT.
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Affiliation(s)
- Ah Young Yoo
- Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, 148, Gurodong-ro, Guro-gu, Seoul 08308, Republic of Korea; (A.Y.Y.); (J.-J.P.); (B.J.L.); (S.H.K.); (W.S.K.)
| | - Moon Kyung Joo
- Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, 148, Gurodong-ro, Guro-gu, Seoul 08308, Republic of Korea; (A.Y.Y.); (J.-J.P.); (B.J.L.); (S.H.K.); (W.S.K.)
| | - Jong-Jae Park
- Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, 148, Gurodong-ro, Guro-gu, Seoul 08308, Republic of Korea; (A.Y.Y.); (J.-J.P.); (B.J.L.); (S.H.K.); (W.S.K.)
| | - Beom Jae Lee
- Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, 148, Gurodong-ro, Guro-gu, Seoul 08308, Republic of Korea; (A.Y.Y.); (J.-J.P.); (B.J.L.); (S.H.K.); (W.S.K.)
| | - Seung Han Kim
- Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, 148, Gurodong-ro, Guro-gu, Seoul 08308, Republic of Korea; (A.Y.Y.); (J.-J.P.); (B.J.L.); (S.H.K.); (W.S.K.)
| | - Won Shik Kim
- Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, 148, Gurodong-ro, Guro-gu, Seoul 08308, Republic of Korea; (A.Y.Y.); (J.-J.P.); (B.J.L.); (S.H.K.); (W.S.K.)
| | - Hoon Jai Chun
- Division of Gastroenterology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, Seoul 02841, Republic of Korea;
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Sarajlic P, Simonsson M, Jernberg T, Bäck M, Hofmann R. Incidence, associated outcomes, and predictors of upper gastrointestinal bleeding following acute myocardial infarction: a SWEDEHEART-based nationwide cohort study. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2021; 8:483-491. [PMID: 34423350 PMCID: PMC9366628 DOI: 10.1093/ehjcvp/pvab059] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/15/2021] [Accepted: 08/02/2021] [Indexed: 01/10/2023]
Abstract
Aims Of all spontaneous bleeding complications in patients with acute myocardial infarction (MI), upper gastrointestinal bleeding (UGIB) is common and of specific interest since it could be prevented by several prophylactic measures. We aimed to determine the incidence, associated outcomes, and predictors of UGIB following acute MI. Methods and results All patients with acute MI enrolled in the SWEDEHEART (Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies) registry from January 2007 to June 2016 and discharged alive on any antithrombotic therapy (n = 149 477) were followed regarding UGIB for 1 year. Associated outcomes were determined by Cox proportional hazards regression with UGIB as a time-dependent covariate, adjusting for baseline characteristics, invasive treatment, and medical treatment at discharge. Predictors of UGIB were determined by logistic regression and machine learning models. At 1 year, UGIB had occurred in 2230 patients (cumulative incidence 1.5%) and was significantly associated with an increased risk of all-cause death [hazard ratio (HR) 2.86, 95% confidence interval (CI) 2.58–3.16] and stroke (HR 1.80, 95% CI 1.32–2.45) but not with recurrent MI (HR 1.17, 95% CI 0.97–1.42). The most important predictors of UGIB were haemoglobin, age, systolic blood pressure, blood glucose, smoking status, previous upper gastrointestinal bleeding, and antithrombotic and gastroprotective treatment. Conclusion After acute MI, readmission because of UGIB is common and significantly associated with poor prognosis. By using machine learning in addition to traditional logistic regression, new predictors of UGIB, such as blood glucose and smoking status, were identified.
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Affiliation(s)
- Philip Sarajlic
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Moa Simonsson
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institute, Stockholm, Sweden.,Theme Heart and Vessels, Division of Valvular and Coronary Disease, Karolinska University Hospital, Stockholm, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Magnus Bäck
- Department of Medicine, Karolinska Institute, Stockholm, Sweden.,Theme Heart and Vessels, Division of Valvular and Coronary Disease, Karolinska University Hospital, Stockholm, Sweden
| | - Robin Hofmann
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institute, Sodersjukhuset, Stockholm, Sweden
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Gupta K, Khan A, Kumar M, Sawalha K, Abozenah M, Singhania R. Readmissions Rates After Myocardial Infarction for Gastrointestinal Bleeding: A National Perspective. Dig Dis Sci 2021; 66:751-759. [PMID: 32436123 DOI: 10.1007/s10620-020-06315-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/02/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND AIMS Gastrointestinal (GI) bleeding is one most common complications of acute myocardial infarction (AMI). We aimed to determine the incidence, in-hospital outcomes, associated healthcare burden and predictors of GI bleeding within 30 days after AMI. METHODS Data were extracted from Nationwide Readmission Database 2010-2014. Patients were included if they had a primary diagnosis of ST or non-ST elevation myocardial infarction. Exclusion criteria were admissioned in December, aged less than 18 years and a diagnosis of type-2 MI. The primary outcome was 30-day readmission with upper or lower GI bleeding. Secondary outcomes were in-hospital mortality, etiology of bleeding, in-hospital complications, procedures, length of stay, and total hospitalization charges. Independent predictors of readmission were identified using multivariate logistic regression analysis. RESULTS Out of the 3,520,241 patients discharged with ACS, 10,018 (0.3%) were readmitted with GI bleeding within 30 days of discharge. 60% had lower GI bleeding. Most common sources suspected were GI cancers in 17% and hemorrhoidal bleeding in 10%. In hospital mortality rate for readmission was 3.6%. Independent predictors of readmission were age, Charlson comorbidity score, history of chronic kidney disease, GI tumor, inflammatory bowel disease and artificial heart valve. Type of treatment for AMI had no impact on readmission. Patients readmitted had higher rates of shock (adjusted odds ratio, 1.48, 95% CI 1.01-3.72). CONCLUSIONS In the first nationwide study, 30-day incidence of GI bleeding after AMI is 0.3%. GI bleeding complicating AMI carries a substantial in-hospital mortality and cost of care.
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Affiliation(s)
- Kamesh Gupta
- Department of Internal Medicine, UMMS-Baystate Medical Center, Springfield, MA, USA.
| | - Ahmad Khan
- Department of Internal Medicine, West Virginia University- Charleston Division, Charleston, WV, USA
| | - Manish Kumar
- Department of Internal Medicine, Yale-Danbury Hospital, Danbury, CT, USA
| | - Khalid Sawalha
- Department of Internal Medicine, UMMS-Baystate Medical Center, Springfield, MA, USA
| | - Mohammed Abozenah
- Department of Internal Medicine, UMMS-Baystate Medical Center, Springfield, MA, USA
| | - Rohit Singhania
- Department of Gastroenterology, UMMS-Baystate Medical Center, Springfield, MA, USA
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Bilal M, Samuel R, Khalil MK, Singh S, Parupudi S, Abougergi MS. Response. Gastrointest Endosc 2021; 93:270-271. [PMID: 33353622 DOI: 10.1016/j.gie.2020.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 08/25/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Mohammad Bilal
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ronald Samuel
- Department of Internal Medicine, The University of Texas Medical Branch, Galveston, Texas
| | | | - Shailendra Singh
- Division of Gastroenterology, West Virginia University, Charleston Area Medical Center, Charleston, West Virginia
| | - Sreeram Parupudi
- Division of Gastroenterology and Hepatology, The University of Texas Medical Branch, Galveston, Texas
| | - Marwan S Abougergi
- Catalyst Medical Consulting, Simpsonville, South Carolina; Division of Gastroenterology, Department of Internal Medicine, University of South Carolina School of Medicine, Columbia, South Carolina, USA
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Zaheer R, Devi J, Siau K. Upper GI hemorrhage after percutaneous coronary intervention. Gastrointest Endosc 2021; 93:270. [PMID: 33353621 DOI: 10.1016/j.gie.2020.07.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 07/07/2020] [Indexed: 02/06/2023]
Affiliation(s)
| | - Jalpa Devi
- Liaquat University of Medical and Health Sciences Jamshoro, Hyderabad, Pakistan
| | - Keith Siau
- University Hospitals Birmingham, Birmingham, UK
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Incidence and Risk Factors for 30-Day Readmission after Inpatient Chemotherapy among Acute Lymphoblastic Leukemia Patients. Healthcare (Basel) 2020; 8:healthcare8040401. [PMID: 33066571 PMCID: PMC7720128 DOI: 10.3390/healthcare8040401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 10/04/2020] [Accepted: 10/12/2020] [Indexed: 11/17/2022] Open
Abstract
Chemotherapy for acute lymphoblastic leukemia (ALL) patients is complex and intense, resulting in a high readmission rate. We aimed to identify the incidence, causes, and risk factors of readmission following inpatient chemotherapy among ALL patients, using 2016 National Readmission Database. We applied three different definitions of 30-day readmission: (1) nonelective readmission based on readmission type, (2) unplanned readmission defined by CMS, and (3) unintentional readmission, combining (1) and (2). We used unweighted multivariable Poisson regression with robust variance estimates for risk factors analysis, including patient-, hospital-, and admission-related characteristics. Percentage for nonelective, unplanned, and unintentional readmission were 33.3%, 22.4%, and 18.5%, respectively. The top three causes for unplanned readmissions were neutropenia/agranulocytosis (27.8%), septicemia (15.3%), and pancytopenia (11.5%). Risk ratios for unintentional readmission were 1.21 (1.08–1.36) for nonelective vs. elective admission, 1.19 (1.06–1.33) for public vs. private insurance enrollees, 0.96 (0.95–0.98) for each day of hospital stay, 0.77 (0.62–0.95) for large teaching and 0.87 (0.70–1.08) for small teaching vs. nonteaching hospitals. Possible strategies to reduce readmission among ALL patients could be shortening the gap in quality of care among teaching vs. non-teaching hospitals, understanding the difference between privately vs. publicly insured patients, and avoiding aggressive discharge after chemotherapy.
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Affiliation(s)
- Mohammad Bilal
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Marwan S Abougergi
- Catalyst Medical Consulting, Simpsonville, South Carolina, USA; Division of Gastroenterology, Department of Internal Medicine, University of South Carolina School of Medicine, Columbia, South Carolina, USA
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Bhurwal A, Goel A, Mutneja H, Patel AV. Does nonvariceal upper GI bleed after percutaneous coronary intervention for myocardial infarction really worsen outcomes? Gastrointest Endosc 2020; 92:460. [PMID: 32703379 DOI: 10.1016/j.gie.2020.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 03/05/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Abhishek Bhurwal
- Gastroenterology and Hepatology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Akshay Goel
- Gastroenterology and Hepatology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Hemant Mutneja
- Gastroenterology and Hepatology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Anish V Patel
- Gastroenterology and Hepatology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
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The challenge of nonvariceal upper GI bleeding management in patients with acute coronary syndrome receiving dual-antiplatelet therapy. Gastrointest Endosc 2020; 92:75-77. [PMID: 32586567 DOI: 10.1016/j.gie.2020.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 03/05/2020] [Indexed: 12/11/2022]
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