1
|
Moussa MD, Soquet J, Robin E, Labreuche J, Rousse N, Rauch A, Loobuyck V, Leroy G, Duburcq T, Gantois G, Leroy X, Ait-Ouarab S, Lamer A, Thellier L, Lukowiak O, Schurtz G, Muller C, Juthier F, Susen S, Vincentelli A. Definitions of major bleeding for predicting mortality in critically ill adult patients who survived 24 hours while supported with peripheral veno-arterial extracorporeal membrane oxygenation for cardiogenic shock: a comparative historical cohort study. Can J Anaesth 2024; 71:523-534. [PMID: 38438682 DOI: 10.1007/s12630-024-02704-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 10/30/2023] [Accepted: 11/01/2023] [Indexed: 03/06/2024] Open
Abstract
PURPOSE The severity of bleeding events is heterogeneously defined during peripheral veno-arterial extracorporeal membrane oxygenation (pVA-ECMO). We studied three bleeding definitions in pVA-ECMO: the Extracorporeal Life Support Organization (ELSO)-serious bleeding, the Bleeding Academic Research Consortium (BARC), and the universal definition of postoperative bleeding (UPDB) classifications. METHODS We included consecutive adult patients supported by pVA-ECMO for refractory cardiogenic shock admitted to Lille academic hospitals between January 2013 and December 2019. We assessed the association of bleeding definitions with the primary endpoint of 28-day all-cause mortality with the use of multivariate models accounting for time-dependent and competing variables. We compared models' performances using the Harrell's C-Index and the Akaike information criteria. RESULTS Twenty-eight-day mortality occurred in 128/308 (42%) 308 patients. The ELSO-serious bleeding (hazard ratio [HR], 1.67; 95% confidence interval [CI], 1.09 to 2.56) and BARC ≥ type 2 (HR, 1.55; 95% CI, 1.01 to 2.37) were associated with 28-day mortality (Harrell's C-index, 0.69; 95% CI, 0.63 to 0.74 for both). Predictors of ELSO-serious bleeding were postcardiotomy, body mass index, baseline platelets count, fibrinogen, and hemoglobin levels. CONCLUSION Extracorporeal Life Support Organization-serious bleeding and BARC ≥ type 2 are relevant definitions of major bleeding regarding their association with mortality in critically ill patients who survived the first 24 hr while supported with pVA-ECMO for cardiogenic shock. STUDY REGISTRATION CERAR (IRB 00010254-2022-050, Paris, France); first submitted on 18 April 2022.
Collapse
Affiliation(s)
- Mouhamed D Moussa
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France.
- Pôle d'Anesthésie-Réanimation, CHU Lille, Lille, France.
- Service d'Anesthésie-Réanimation Cardiovasculaire et thoracique, Institut Cœur - Poumon, CHU Lille, 2 avenue Oscar Lambret, 59 037, Lille, France.
| | - Jérôme Soquet
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Department of Cardiac Surgery, CHU Lille, Lille, France
| | - Emmanuel Robin
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Pôle d'Anesthésie-Réanimation, CHU Lille, Lille, France
| | | | - Natacha Rousse
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Department of Cardiac Surgery, CHU Lille, Lille, France
| | - Antoine Rauch
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
| | - Valentin Loobuyck
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Department of Cardiac Surgery, CHU Lille, Lille, France
| | | | | | | | - Xavier Leroy
- Pôle d'Anesthésie-Réanimation, CHU Lille, Lille, France
| | | | - Antoine Lamer
- Pôle d'Anesthésie-Réanimation, CHU Lille, Lille, France
| | - Lise Thellier
- Pôle d'Anesthésie-Réanimation, CHU Lille, Lille, France
| | | | - Guillaume Schurtz
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Department of Cardiology, CHU Lille, Lille, France
| | | | - Francis Juthier
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Department of Cardiac Surgery, CHU Lille, Lille, France
| | - Sophie Susen
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
| | - André Vincentelli
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Department of Cardiac Surgery, CHU Lille, Lille, France
| |
Collapse
|
2
|
Vranckx P, White HD, Huang Z, Mahaffey KW, Armstrong PW, Van de Werf F, Moliterno DJ, Wallentin L, Held C, Aylward PE, Cornel JH, Bode C, Huber K, Nicolau JC, Ruzyllo W, Harrington RA, Tricoci P. Validation of BARC Bleeding Criteria in Patients With Acute Coronary Syndromes: The TRACER Trial. J Am Coll Cardiol 2017; 67:2135-2144. [PMID: 27151345 DOI: 10.1016/j.jacc.2016.02.056] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 02/09/2016] [Accepted: 02/24/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Bleeding Academic Research Consortium (BARC) scale has been proposed to standardize bleeding endpoint definitions and reporting in cardiovascular trials. Validation in large cohorts of patients is needed. OBJECTIVES This study sought to investigate the relationship between BARC-classified bleeding and mortality and compared its prognostic value against 2 validated bleeding scales: TIMI (Thrombolysis In Myocardial Infarction) and GUSTO (Global Use of Strategies to Open Occluded Arteries). METHODS We analyzed bleeding in 12,944 patients with acute coronary syndromes without ST-segment elevation, with or without early invasive strategy. The main outcome measure was all-cause death. RESULTS During follow-up (median: 502 days), noncoronary artery bypass graft (CABG) bleeding occurred in 1,998 (15.4%) patients according to BARC (grades 2, 3, or 5), 484 (3.7%) patients according to TIMI minor/major, and 514 (4.0%) patients according to GUSTO moderate/severe criteria. CABG-related bleeding (BARC 4) occurred in 155 (1.2%) patients. Patients with BARC (2, 3, or 4) bleeding had a significant increase in risk of death versus patients without bleeding (BARC 0 or 1); the hazard was highest in the 30 days after bleeding (hazard ratio: 7.35; 95% confidence interval: 5.59 to 9.68; p < 0.0001) and remained significant up to 1 year. The hazard of mortality increased progressively with non-CABG BARC grades. BARC 4 bleeds were significantly associated with mortality within 30 days (hazard ratio: 10.05; 95% confidence interval: 5.41 to 18.69; p < 0.0001), but not thereafter. Inclusion of BARC (2, 3, or 4) bleeding in the 1-year mortality model with baseline characteristics improved it to an extent comparable to TIMI minor/major and GUSTO moderate/severe bleeding. CONCLUSIONS In patients with acute coronary syndromes without ST-segment elevation, bleeding assessed with the BARC scale was significantly associated with risk of subsequent death up to 1 year after the event and risk of mortality increased gradually with higher BARC grades. Our results support adoption of the BARC bleeding scale in ACS clinical trials. (Trial to Assess the Effects of Vorapaxar [SCH 530348; MK-5348] in Preventing Heart Attack and Stroke in Participants With Acute Coronary Syndrome [TRACER] [Study P04736]; NCT00527943).
Collapse
Affiliation(s)
| | - Harvey D White
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Zhen Huang
- Duke Clinical Research Institute, Durham, North Carolina
| | | | | | | | - David J Moliterno
- Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Claes Held
- Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Philip E Aylward
- SAHMRI, Flinders University and Medical Centre, Adelaide, Australia
| | - Jan H Cornel
- Department of Cardiology, Medisch Centrum Alkmaar, Alkmaar, the Netherlands
| | - Christoph Bode
- Internal Medicine and Cardiology, Universitätsklinikum, Freiburg, Germany
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria
| | - José C Nicolau
- Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Witold Ruzyllo
- Department of Coronary Artery Disease and Cardiac Catheterization Laboratory, Institute of Cardiology, Warsaw, Poland
| | | | | |
Collapse
|
3
|
Rao SV, McCoy LA, Spertus JA, Krone RJ, Singh M, Fitzgerald S, Peterson ED. An updated bleeding model to predict the risk of post-procedure bleeding among patients undergoing percutaneous coronary intervention: a report using an expanded bleeding definition from the National Cardiovascular Data Registry CathPCI Registry. JACC Cardiovasc Interv 2014; 6:897-904. [PMID: 24050858 DOI: 10.1016/j.jcin.2013.04.016] [Citation(s) in RCA: 189] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 04/18/2013] [Accepted: 04/18/2013] [Indexed: 12/19/2022]
Abstract
OBJECTIVES This study sought to develop a model that predicts bleeding complications using an expanded bleeding definition among patients undergoing percutaneous coronary intervention (PCI) in contemporary clinical practice. BACKGROUND New knowledge about the importance of periprocedural bleeding combined with techniques to mitigate its occurrence and the inclusion of new data in the updated CathPCI Registry data collection forms encouraged us to develop a new bleeding definition and risk model to improve the monitoring and safety of PCI. METHODS Detailed clinical data from 1,043,759 PCI procedures at 1,142 centers from February 2008 through April 2011 participating in the CathPCI Registry were used to identify factors associated with major bleeding complications occurring within 72 h post-PCI. Risk models (full and simplified risk scores) were developed in 80% of the cohort and validated in the remaining 20%. Model discrimination and calibration were assessed in the overall population and among the following pre-specified patient subgroups: females, those older than 70 years of age, those with diabetes mellitus, those with ST-segment elevation myocardial infarction, and those who did not undergo in-hospital coronary artery bypass grafting. RESULTS Using the updated definition, the rate of bleeding was 5.8%. The full model included 31 variables, and the risk score had 10. The full model had similar discriminatory value across pre-specified subgroups and was well calibrated across the PCI risk spectrum. CONCLUSIONS The updated bleeding definition identifies important post-PCI bleeding events. Risk models that use this expanded definition provide accurate estimates of post-PCI bleeding risk, thereby better informing clinical decision making and facilitating risk-adjusted provider feedback to support quality improvement.
Collapse
Affiliation(s)
- Sunil V Rao
- Duke Clinical Research Institute, Durham, North Carolina.
| | | | | | | | | | | | | |
Collapse
|