Incidence, predictors, and prognostic impact of bleeding after hospital discharge following acute coronary syndrome: A cohort study within the Clinical Practice Research Datalink.

Problem

Background – The secondary management of acute coronary syndrome (ACS) with antithrombotic medication achieves the desired goal of reducing adverse ischaemic events, albeit at the expense of increased bleeding complications. The incidence and prognostic impact of major bleeding has been well-characterised within the clinical trial setting. However, little is known about the extent of these bleeding events post-hospital discharge.Objective – To determine the incidence, predictors and prognostic impact of bleeding on all-cause mortality post-hospital discharge post ACS.

Approach

We used the Clinical Practice Research Datalink (CPRD), with linkage to Hospital Episode Statistics (HES), to identify patients with ACS diagnosis between 2006 and 2016. Patients were followed from date of hospital discharge for records of bleeding consultations post ACS. The incidence, timing, and types of bleeding events within 12 months of hospital discharge were determined. We assessed independent associations between post-discharge bleeding and baseline patient characteristics using a competing risk model, accounting for the death as a competing event. The association of bleeding with all-cause mortality was assessed using a standard Cox model.

Findings

Among 27,660 patients surviving to hospital discharge, 3,620 (13%) experienced bleeding complications at a median time of 123 days (IQR: 45, 223) post-hospital discharge. The incidence of bleeding within 12 months of hospital discharge was 162/1000 persons years. Bruising (26%) was the most common type of first bleeding event, followed by gastrointestinal bleed (19%). Significant predictors of post-discharge bleeding included prior history of bleeding complication, oral anticoagulant prescription, history of peripheral vascular disease, chronic obstructive pulmonary disease, and advanced age >80 years. Bleeding increased the risk of all-cause mortality post hospital discharge for ACS.

Consequences

Bleeding complications post-hospital discharge are common within the primary care setting, and carry a greater risk of mortality. Patients who experience these bleeding events have distinct baseline characteristics. These characteristics can inform risk-benefit considerations in deciding on favourable combination and duration of secondary antithrombotic therapy.