Bleeding Calculator Use Linked to Dramatic Decrease in Post-PCI Bleeding

ORLANDO, FL—Using a calculator to assess individual bleeding risk prior to PCI not only reduces bleeding, it motivates operators to do more transradial procedures, saves money, and leads to more patients being discharged home the same day, new research suggests. 

In a presentation yesterday at SCAI 2016, Jerome E. Granato, MD (Catholic Health Initiatives, Lexington, KY), presented a multicenter study that tracked variations in patient and hospital factors among more 200 physicians who performed PCI procedures between 2013 and 2015. A total of 8,713 PCIs were included from 2015 alone.

“In examining these procedures, we were struck by the variability in how PCI was being performed,” Granato said. Use of bivalirudin, for example, ranged from zero to 100%, with no correlation to bleeding events.

The researchers requested that operators in the study use the National Cardiovascular Data Registry (NCDR) bleeding risk calculator, and therapeutic recommendations were made according to the likelihood of a bleeding event. Those with a risk score < 25 were characterized as low risk. In these patients, bivalirudin use was discouraged, while heparin use was promoted. In those at intermediate risk (scores of 26-65), approach and anticoagulation choice were left to the discretion of the operator. Lastly, for those considered at high risk (scores of 66 and higher) bivalirudin with transradial access was highly encouraged.

According to Granato, adoption of the risk calculator “was early, complete, and consistent over time” at each of the sites in the study.

“While therapeutic decisions and arterial access method was left up to each physician, we closely monitored the extent to which facilities complied with the calculator’s use and recommendation,” he said.

Strikingly, bivalirudin use fell from 57% of all procedures to 35%, a decrease of nearly 40% from the start to the end of the study, Granato noted. This correlated with a $1 million decrease per year in pharmacy costs. At the same time, bleeding events declined by about the same amount, and transradial access procedures increased from 32.9% in 2013 to 39.7% in 2014, topping out at 54.0% in 2015. Meanwhile, the same-day discharge rate increased from 11.5% to 14.3%.

Not Sexy, but Definitely Important

Granato was asked whether there was any suggestion that the bleeding-reduction strategy was associated with an increase in ischemic events. He responded that no real change was seen in ischemic events, including stent thrombosis. He added that his group believes the reductions in bleeding were largely the result of fewer access-site bleeds as opposed to non-access-site bleeds, but said data are not available from this study to assess that.

Panelist Sunil V. Rao, MD (Duke University Medical Center, Durham, NC), told TCTMD he is a big believer in risk calculators, saying that while this type of study may not be “sexy,” it is important to patients.

“The key though is you’ve got to integrate it into your normal work flow,” he said. “So where we need to get to for electronic health records is for that stuff to be automatically calculated and presented to you for every patient. Then it becomes very easy to integrate it into your practice. We know, based on a fair amount of data, that the presentation of risk scores to physicians alters their behavior. So just having that information allows you to make better choices.”

Source:

• Granato JE. Risk directed interventions in percutaneous coronary intervention (PCI): an enterprise approach for reducing bleeding events. Presented at: SCAI 2016; May 4, 2016; Orlando, FL.

Disclosures:

• Granato reports grants to his institution from The Medicines Company. 
• Rao reports consulting for and serving on the advisory board/speakers bureau for Medtronic, and consulting for and serving on the advisory board for Terumo Interventional Systems Inc. 

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