1. How to Minimize Bleeding in STEMI Patients Outline: -Know about bleeding -Think about consequences of bleeding -Identify bleeding risk factors -Maximize risk : benefit Steven V. Manoukian, M.D., F.A.C.C., F.S.C.A.I. Vice President and Medical Director of Cardiovascular Services Hospital Corporation of America (HCA) Nashville, Tennessee Disclosures: COI-none, Off Label-yes

2. I/we have no real or apparent conflicts of interest to report.
Steven V. Manoukian, MD
I/we have no real or apparent conflicts of interest to report.

3. Rates of PCI Bleeding: NCDR 2010-11
PCI Patients Without STEMI (n=787,980)
PCI Patients With STEMI (n=153,268)
CathPCI Bleeding: (1) occurring at percutaneous entry site, during or after cath lab visit until dc, may be external or hematoma >10 cm femoral, >5 cm brachial, or >2 cm radial; (2) retroperitoneal; (3) GI; (4) GU; and (5) other/unknown during or after cath lab visit until dc. All bleeding events required transfusion, prolonged stay, and/or drop in Hgb >3.0 g/dL.
Dehmer GJ et al. JACC 2012.

4. Types of CCL Bleeding: NCDR 2010-11
Dehmer GJ et al. JACC 2012.

5. Impact of Bleeding on Mortality (ACS)
Manoukian SV, Feit F, Mehran R, et al. J Am Coll Cardiol 2007;49:

6. Severity of Bleeding and Impact on Mortality (R2, ACUITY, HORIZONS)
Mehran R et al. JACC INTV 2011.

7. Patient Risk Factors for Bleeding (ACS)
Manoukian SV, Feit F, Mehran R, et al. J Am Coll Cardiol 2007;49:

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

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

10. Bleeding Risk Score (NCDR)
Ahmed B and Dauerman HL. Circulation 2013.

11. PCI Anticoagulation Use 2010-11 (NCDR)
Dehmer GJ et al. JACC 2012.

12. HCA Anticoagulation Use: Abciximab, Eptifibatide, Tirofiban and Bivalirudin Percentage of Overall Dollars (Estimates)
Abciximab 7%
Bivalirudin 59%
Eptifibatide 34%
Tirofiban <1%

13. PCI Bleeding and Pharmacology in STEMI HORIZONS 30-Day Endpoints
Stone GW et al. NEJM 2008.

14. PCI Bleeding and Pharmacology Across Presentations
30-Day: REPLACE-2, ACUITY-PCI, HORIZONS ITT
STEMI
ACS
PCI
Adapted from REPLACE-2, ACUITY-PCI, HORIZONS ITT.

15. Avoidance of Excess Pharmacology Dosing
Alexander KP, et al. JAMA 2005;294:

16. Avoidance of Excess Pharmacology Duration in PCI Shortened Course of Glycoprotein IIb/IIIa Inhibition BRIEF-PCI Trial
Fung AY et al. JACC 2009.

17. Avoidance of Excess Pharmacology Duration in PCI Shortened Aggrastat vs. Integrilin in PCI SAVI-PCI Trial
600 patients undergoing elective or ACS PCI in approximately 20 U.S. centers
Tirofiban
1-2 hour infusion
25 mcg/kg mcg/kg/min
Eptifibatide
12-18 hour infusion
Standard Dosing
Endpoints:
Death, MI, UR or bleeding at discharge or 48 hours, whichever comes first.
Hypothesis: Efficacy will be maintained with a 50-75% reduction in bleeding and transfusion.
Manoukian SV et al.

18. FABOLUS PRO: Prasugrel vs. Tirofiban in STEMI
Valgimigli M et al. JACC INTV 2012.

19. Non-Pharmacologic Approaches to Bleeding: Access Site Utilization 2010-11 (NCDR)
Dehmer GJ et al. JACC 2012.

20. Non-Pharmacologic Approaches to Bleeding: r-PCI Success and Complication Rates
Rao SV et al. JACC Intv 2008;1:

21. Non-Pharmacologic Approaches to Bleeding: Vascular Closure Devices
Major ASB = Hgb drop >3, RP bleed, ASB operation, hematoma >5cm.
Sanborn TA, Ebrahimi R, Manoukian SV et al. Circ Cardiovasc Interv 2010;3:57-62.

22. Comprehensive Approaches to Bleeding: Individualized ePRISM Informed Consents
Courtesy, Spertus JA.

23. Conclusions Know about bleeding Think about consequences of bleeding
Rates increase with STEMI
Half are access site-related
Think about consequences of bleeding
Associated with mortality, adverse outcomes
Linked to cost, LOS, readmission
Identify bleeding risk factors
Especially age, sex, renal, anemia, presentation
Perform individualized baseline assessment
Do maximize risk : benefit
Pharmacologic: drug, dose, duration
Non-pharmacologic: site, size, VCD, IABP