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Major bleeding after percutaneous coronary intervention and risk of subsequent mortality: a systematic review and meta-analysis
  1. Chun Shing Kwok1,
  2. Sunil V Rao2,
  3. Phyo K Myint3,
  4. Bernard Keavney1,
  5. James Nolan4,
  6. Peter F Ludman5,
  7. Mark A de Belder6,
  8. Yoon K Loke7 and
  9. Mamas A Mamas1
  1. 1Cardiovascular Institute, University of Manchester, Manchester, UK
  2. 2Department of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
  3. 3Division of Applied Health Sciences, School of Medicine & Dentistry, University of Aberdeen, Aberdeen, Scotland, UK
  4. 4Department of Cardiology, University Hospital North Staffordshire, Stoke-on-Trent, UK
  5. 5Department of Cardiology, Queen Elizabeth Hospital, Birmingham, UK
  6. 6Cardiothoracic Division, The James Cook University Hospital, Middlesbrough, UK
  7. 7Norwich Medical School, University of East Anglia, Norwich, UK
  1. Correspondence to Dr Mamas A Mamas; mamasmamas1{at}


Objectives To examine the relationship between periprocedural bleeding complications and major adverse cardiovascular events (MACEs) and mortality outcomes following percutaneous coronary intervention (PCI) and study differences in the prognostic impact of different bleeding definitions.

Methods We conducted a systematic review and meta-analysis of PCI studies that evaluated periprocedural bleeding complications and their impact on MACEs and mortality outcomes. A systematic search of MEDLINE and EMBASE was conducted to identify relevant studies. Data from relevant studies were extracted and random effects meta-analysis was used to estimate the risk of adverse outcomes with periprocedural bleeding. Statistical heterogeneity was assessed by considering the I2 statistic.

Results 42 relevant studies were identified including 533 333 patients. Meta-analysis demonstrated that periprocedural major bleeding complications was independently associated with increased risk of mortality (OR 3.31 (2.86 to 3.82), I2=80%) and MACEs (OR 3.89 (3.26 to 4.64), I2=42%). A differential impact of major bleeding as defined by different bleeding definitions on mortality outcomes was observed, in which the REPLACE-2 (OR 6.69, 95% CI 2.26 to 19.81), STEEPLE (OR 6.59, 95% CI 3.89 to 11.16) and BARC (OR 5.40, 95% CI 1.74 to 16.74) had the worst prognostic impacts while HORIZONS-AMI (OR 1.51, 95% CI 1.11 to 2.05) had the least impact on mortality outcomes.

Conclusions Major bleeding after PCI is independently associated with a threefold increase in mortality and MACEs outcomes. Different contemporary bleeding definitions have differential impacts on mortality outcomes, with 1.5–6.7-fold increases in mortality observed depending on the definition of major bleeding used.


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