Trends in Bleeding Events Among Patients With Acute Coronary Syndrome in China, 2015 to 2019: Insights From the CCC-ACS Project

Abstract

Objective: Major bleeding is a common complication following treatment for an acute coronary syndrome (ACS) and is associated with increased mortality. We aimed to explore the temporal trend of bleeding events in relation to changes of therapeutic strategies among patients hospitalized for ACS in China. Methods: The CCC-ACS project (Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome) is a collaborative initiative of the American Heart Association and the Chinese Society of Cardiology. We analyzed 113,567 ACS patients from 241 hospitals in China from 2015 to 2019. Major bleeding was defined as intracranial bleeding, retroperitoneal bleeding, a decline in hemoglobin levels ≥3 g/dL, transfusion with overt bleeding, bleeding requiring surgical intervention, and fatal bleeding. Kruskal-Wallis test was used to examine the trend of major bleeding over time. Results: The rate of in-hospital major bleeding decreased from 6.3% in 2015 to 4.7% in 2019 (unadjusted OR = 0.74, 95% CI: 0.68-0.80, and P < 0.001). The relative changes were consistent across almost all subgroups including patients with NSTE-ACS and STEMI, although the trend was more pronounced in NSTE-ACS patients. The decrease in bleeding was accompanied by a decrease in use of GP IIb/IIIa inhibitors and parenteral anticoagulation therapy during hospitalization. The annual reduced risk of bleeding (OR = 0.91, 95% CI: 0.89-0.93) was attenuated after stepwise adjusting for baseline characteristics and antithrombotic treatments (OR = 0.95, 95% CI: 0.93-0.97), but did not change after adjusting for invasive treatment (OR = 0.95, 95% CI: 0.93-0.97). Conclusions: There was a temporal reduction in in-hospital bleeding among Chinese ACS patients during the last 5 years, which was associated with more evidence-based use of antithrombotic therapies. Clinical Trial Registration: https://www.clinicaltrials.gov, identifier: NCT02306616.

Keywords: acute coronary syndrome; antithrombotic therapy; bleeding; outcome; temporal trend.

Conflict of interest statement

GF consulted for Amgen, AstraZeneca, Bayer, Janssen, and Novartis and served on the AHA's Quality Oversight Committee. CM received honoraria from Bristol-Myers Squibb (BMS), Pfizer, Johnson & Johnson, Boehringer-Ingelheim (BI), Bayer and AstraZeneca for giving lectures. SN received research grants from the institution from Boston Scientific, Abbott, Jiangsu Hengrui Pharmaceuticals, China Resources Sanjiu Medical & Pharmaceuticals, East China Pharmaceuticals. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2021 Wang, Zhao, Zhou, Ma, Ge, Huo, Smith, Fonarow, Hao, Liu, Morgan, Gong, Yan, Liu, Zhao, Han and Nie.

Figures

Figure 1

Temporal trend of in-hospital outcomes and treatment, 2015–2019. (A) Trends in rate of bleeding for all patients and per subgroup of STEMI, NSTEMI, and UAP. (B) Trends in invasive and antithrombotic therapy in all ACS patients. (C) Bleeding vs. MACE in all ACS patients. (D) Combined bleeding and ischemic outcomes in all ACS patients. ACS, acute coronary syndrome; DAPT, dual antiplatelet therapy; MACE, major adverse cardiovascular events; NSTE-ACS, non-ST-segment elevation acute coronary syndrome; NSTEMI, non-ST-segment elevation myocardial infarction; PCI, percutaneous coronary intervention; STEMI, ST-segment elevation myocardial infarction; UAP, unstable angina pectoris.

Figure 2

Association between 1 year change in time-period and major bleeding in all ACS patients and per subgroup of NSTE-ACS and STEMI. Stepwise adjustments as follows: (1) crude; (2) age and gender; (3) baseline characteristics (diabetes mellitus, hypertension, eGFR 2, STEMI, and Killip class); (4) in-hospital antithrombotic treatments (GPIIb/IIIa inhibitor use, anticoagulant treatment, and ticagrelor use); and (5) invasive treatments [PCI (for STEMI, primary PCI), transradial access]. ACS, acute coronary syndrome; NSTE-ACS, non-ST-segment elevation acute coronary syndrome; PCI, percutaneous coronary intervention; STEMI, ST-segment elevation myocardial infarction.