April 11th, 2013
Bleeding Avoidance Strategies for PCI in Women vs. Men
John Ryan interviews Stacie Daugherty, lead author of a study recently published online by JACC on differences in rates of bleeding and bleeding avoidance strategies (BAS) between women and men undergoing PCI.
Investigators used data from the CathPCI registry to analyze the use of BAS (radial access, bivalirudin, vascular closure devices, or any combination) and bleeding outcomes in men and women. They found that despite similar rates of BAS use in men and in women, bleeding complications occurred significantly more frequently in women. Compared with no BAS, the use of BAS reduced bleeding rates to a similar degree in men and women, but because of the higher overall bleeding rates in women, the absolute reduction in women was much greater than in men.
THE AUTHOR RESPONDS:
Ryan: Were you surprised that the overall rates of BAS use were comparable in men and women?
Daugherty: Given previous data showing higher bleeding rates in women compared with men after PCI, we hypothesized that a portion of this difference might be related to less use of BAS in women. Our findings suggest that women and men undergoing PCI equally receive any form of BAS. Furthermore, other researchers have demonstrated a risk–treatment paradox in BAS use whereby higher-risk patients receive BAS less often than lower-risk patients; we found that the paradox applies to both men and women. This is particularly concerning for women, because a larger proportion of them fall into the high predicted bleeding risk category compared with men (53% vs. 23%; P<0.01). Therefore, one could argue that BAS should be used more frequently in women than men given their higher predisposition to bleeding.
Ryan: What are the major obstacles to using BAS for practitioners?
Daugherty: Due to the observational nature of our data, we were unable to determine the reasons why practitioners did not employ BAS. For example, patients may not have received a radial approach due to inappropriate anatomy; closure devices may not have been used due to high arteriotomy sites; or radial access or closure device use may have been attempted and failed. Therefore, a portion of those who did not receive BAS may not have been ideal candidates. We also suspect that there may be variation by site as to which BAS, if any, is most commonly used. Site-based differences in the use of bleeding avoidance strategies may be influenced by local culture, operator preference, operator experience, laboratory volume, laboratory protocols, and costs. We are interested in examining these potential factors in future studies.
Ryan: Do you feel that a 75% use rate is sufficient, and how would you increase the use of BAS?
Daugherty: Current clinical guidelines for PCI recommend considering bleeding risk in all patients; however, the guidelines do not provide specific recommendations for when BAS should be used. Therefore, the expected or appropriate rate of BAS use remains unclear. There has been substantial debate around the effectiveness of different BAS strategies, particularly closure devices. The evidence supporting reduced bleeding with the use of bivalirudin and radial approach is more robust. Further research is needed to help define the most effective BAS and optimizing patient selection for these therapies.