Pre-Procedural Estimate of Individualized Bleeding Risk Impacts Physicians' Utilization of Bivalirudin During Percutaneous Coronary Intervention

• Published in: Journal of the American College of Cardiology 2013-05, Vol.61 (18), p.1847-1852
• Main Authors: Rao, Seshu C., MD, Chhatriwalla, Adnan K., MD, Kennedy, Kevin F., MS, Decker, Carole J., RN, PhD, Gialde, Elizabeth, RN, MSN, Spertus, John A., MD, MPH, Marso, Steven P., MD
• Format: Article
• Language: English
• Subjects: Acute coronary syndromes; Aged; Antithrombins - administration & dosage; Biological and medical sciences; bivalirudin; bleeding; bleeding risk; Blood. Blood coagulation. Reticuloendothelial system; Cardiology; Cardiology. Vascular system; Cardiovascular; Cardiovascular disease; catheterization; Clinical Competence; Confidence intervals; Coronary Disease - surgery; Coronary heart disease; Coronary vessels; Diseases of the cardiovascular system; Estimates; Female; Heart; Heart attacks; Heart failure; Hemorrhage; Hemorrhage - diagnosis; Hemorrhage - epidemiology; Hirudins - administration & dosage; Humans; Hypertension; Incidence; Internal Medicine; Laboratories; Male; Medical sciences; Middle Aged; Missouri - epidemiology; Mortality; PCI; Peptide Fragments - administration & dosage; Percutaneous Coronary Intervention; Pharmacology. Drug treatments; Preoperative Period; Radiotherapy. Instrumental treatment. Physiotherapy. Reeducation. Rehabilitation, orthophony, crenotherapy. Diet therapy and various other treatments (general aspects); Recombinant Proteins - administration & dosage; Retrospective Studies; Risk assessment; Risk Assessment - utilization; Risk Factors; Stratigraphy; Trends; Variables
• ISSN: 0735-1097; 1558-3597
• DOI: 10.1016/j.jacc.2013.02.017

Objectives This study sought to assess whether incorporation of routine bleeding risk estimates affected the utilization of bivalirudin during percutaneous coronary intervention (PCI). Background Bivalirudin use during PCI has been shown to reduce bleeding complications. However, a risk–treatment paradox exists, in which patients at highest risk for bleeding are least likely to receive bivalirudin. Whether routine estimation of individualized bleeding risk can affect physicians' use of bivalirudin is unknown. Methods PCI data from a single health system between 2007 and 2011 were analyzed. Beginning in July 2009, individualized bleeding risk estimates were provided immediately preceding PCI. Using a pre–post design, we compared bivalirudin use before and after this implementation, for patients across 3 strata of bleeding risk (3%). Results Data from 6,491 PCI procedures were analyzed. Overall, bivalirudin use increased in the post-implementation period (26.9% vs. 34.2%, p < 0.001). Bivalirudin use increased in intermediate (27% to 35%, p < 0.001) and high bleeding risk patients (25% to 43%, p < 0.001), and decreased in low-risk patients (30% to 25%, p = 0.014). During the same period, bleeding complications decreased in intermediate-risk (3.4% to 1.8%, p = 0.009) and high-risk (6.9% to 3.7%, p = 0.005) patients and remained unchanged in low-risk patients (1.1% to 1.0%, p = 0.976). Conclusions There was an increase in bivalirudin use and a lower incidence of bleeding after the incorporation of individualized bleeding risk estimates into clinical practice. This implementation led to a reversal of the risk–treatment paradox, through a rational increase in bivalirudin use in patients at intermediate and high bleeding risk and decreased use in lower-risk patients.