Bleeding in the HBR Patient Sunil V. Rao MD Disclosures n No - PowerPoint PPT Presentation

Best Practices for Reducing Procedural Bleeding in the HBR Patient Sunil V. Rao MD

Disclosures n No relationships with industry n American Heart Association – payment for role as Editor-in- Chief of Circulation: Cardiovascular Interventions n Off-label uses of drugs or devices may be discussed

Bleeding & Outcomes N=26,452 pts from PURSUIT, GUSTO IIb, PARAGON A & B Kaplan Meier Curves for 30-Day Death, Stratified by Bleed Severity log rank p-value for all four categories <0.0001 log-rank p-value for no bleeding vs. mild bleeding = 0.02 log-rank p-value for mild vs. moderate bleeding <0.0001 log-rank p-value for moderate vs. severe <0.001 Rao SV, et al. Am J Cardiol . 2005

Access site and non-access site bleeding and outcomes N=25 studies, 2.4 million pts Kwok CS, et. al. Circ Intv 2015

Bleeding – Mechanisms of harm & Strategies to reduce risk Mechanisms Strategies n Confounding n Identify who is at risk so you can “Sick people bleed, and sick people l use bleeding avoidance strategies die” n Judicious use of blood transfusion n Severe bleeding n Pharmacotherapy Hypotension l Reversal of antithrombotic therapy l n Vascular access n Mild or Moderate bleeding U/S for femoral access l Cessation of antithrombotic therapy 1 l Radial access l Blood transfusion 2 l 1 Wang TY, et. al. Circulation 2008 2 Rao SV, et. al. JAMA 2004

Who is at risk for bleeding? n Older age n Female sex n Anemia n Low body weight n Poor renal function n Shock Rao SV, et. al. JACC Intv 2013

Bivalirudin vs. UFH ± 2b3a N=16 RCTs, 33958 pts Cavender MA, Sabatine MS. Lancet 2014

FAUST Trial - Ultrasound guidance N=1004 pts at 4 centers randomized to U/S or FG All patients receive manual palpation of landmarks U/S guidance – direct visualization of bifurcation and anterior arterial wall FG – radio-opaque marker placed and femoral head identified in AP projection Seto, AH. et. al. JACC Intv 2010

Ultrasound guidance N=1004 pts at 4 centers randomized to U/S or FG *P < 0.01 Seto, AH. et. al. JACC Intv 2010

Radial approach in ACS patients – bleeding and mortality Pooled analysis of 4 trials, 17,133 pts Major Bleeding Mortality Mortality Andò G, Capodanno D. Annals of Internal Medicine 2015

SAFARI-STEMI Mortality in STEMI pts in randomized trials

Mechanism of mortality benefit N=8404 pts in MATRIX trial Prevention of AKI is the predominantly responsible for mortality benefit of radial NNT = 295 Black bars denote mortality Gray bars denote nonfatal endpts Rothenbüler M, et. al. EHJ 2019

Reducing procedural bleeding Identify who is at risk – tools available Pay attention to pharmacotherapy Access site strategies U/S guidance especially for femoral approach Radial access

Thank you Email: sunil.rao@duke.edu Twitter @SVRao MD @CircIntv #RadialFirst