How To Minimize Bleeding In The Cath Lab Steven V. Manoukian, MD, FACC, FSCAI Director of Cardiovascular Research, Sarah Cannon Research Institute Medical Director of Cardiovascular Services, Hospital Corporation of America Nashville, Tennessee

Disclosures Relevant COI: None Off-label: Yes

Outline Look at the patient for bleeding risk factors Bleeding assessment Think about the consequences of bleeding Impact of bleeding Do maximize risk : benefit while enhancing outcomes Pharmacologic approaches (anticoagulation) Non-pharmacologic approaches (radial, VCDs)

Bleeding and Mortality in ACS (ACUITY) Manoukian SV et al. JACC 2007.

Predictors of Mortality in ACS (ACUITY) Manoukian SV et al. JACC 2007.

Outcomes With / Without Bleeding in ACS (ACUITY) Manoukian SV et al. JACC 2007.

Predictors of Bleeding in ACS (ACUITY) Manoukian SV et al. JACC 2007.

Predictors of Bleeding in PCI (REPLACE-2) Feit F et al. AJC 2007.

Bleeding Risk Score (R2, ACUITY, HORIZONS) Mehran R et al. JACC INTV 2011.

Bleeding Risk Score (R2, ACUITY, HORIZONS) Mehran R et al. JACC INTV 2011.

Bleeding Risk Score (R2, ACUITY, HORIZONS) Mehran R et al. JACC INTV 2011.

Bleeding Avoidance: Bivalirudin in ACS (ACUITY) Stone GW et al. NEJM 2006.

Bleeding Avoidance: Truncated GPI (BRIEF-PCI) Eptifibatide <2H vs Bleeding Avoidance: Truncated GPI (BRIEF-PCI) Eptifibatide <2H vs. 18H, Periprocedural Myonecrosis Fung AY et al. JACC 2009.

Bleeding Avoidance: Truncated GPI (BRIEF-PCI) Eptifibatide <2-h vs Bleeding Avoidance: Truncated GPI (BRIEF-PCI) Eptifibatide <2-h vs. 18-h, REPLACE-2 Bleeding Events Fung AY et al. JACC 2009.

Bleeding Avoidance: Radial Proportion of PCI Cases Performed Via the Radial 593,094 PCIs. 606 sites. NCDR 2004-2007. Radial total = 1.32% % of Cath Labs Rao SV et al. JACC 2009.

Bleeding Avoidance: Radial Procedural Success and Bleeding Complications 593,094 PCIs. 606 sites. NCDR 2004-2007. Radial total = 1.32% Rao SV et al. JACC 2009.

Bleeding Avoidance: Radial Outcomes by Access Site (ACUITY) Hamon M et al. EuroIntervention 2009.

Bleeding Avoidance: Radial Bleeding by Access Site and Treatment (ACUITY) Hamon M et al. EuroIntervention 2009.

Bleeding Avoidance: Vascular Closure Devices Major Access Site Bleeding (ACUITY) Sanborn TA et al. Circ Cardiovasc Interv 2010.

Bleeding Avoidance: VCD + Bivalirudin Major ASB by VCD and Treatment (ACUITY) Sanborn TA et al. Circ Cardiovasc Interv 2010.

Bleeding Avoidance: Vascular Closure Devices Predictors of Major ASB (ACUITY) Sanborn TA et al. Circ Cardiovasc Interv 2010.

Bleeding Avoidance: Same-Day Discharge and No Readmission Penalty? Elective PCI in Older (>65 years) Adults Rao SV et al. JAMA 2011.

Conclusions Look at the patient for bleeding risk factors Bleeding assessment Age, gender, renal function, anemia, acuity of presentation Think about the consequences of bleeding Impact of bleeding Associated with mortality, ischemic events, stent thrombosis Do maximize risk : benefit while enhancing outcomes Pharmacologic approaches (anticoagulation) Bivalirudin and truncated regimens of GPI Non-pharmacologic approaches (radial, VCDs) Radial for sure VCDs still require further study