1. Antiplatelet Therapy Use after Discharge among Acute Myocardial Infarction Patients with In-hospital Bleeding
Tracy Y. Wang, MD, MHS, Lan Xiao, PhD, Karen P. Alexander, MD, Sunil V. Rao, MD, Mikhail N. Kosiborod, MD, John S. Rumsfeld, MD, PhD, John A. Spertus, MD, MPH, and Eric D. Peterson, MD, MPH
Wang TY et al, Circulation 2008

2. Background
Antithrombotic therapies are important in the management of patients with acute myocardial infarction (AMI), but incur an increased risk of bleeding complications
Prior studies have established an association between bleeding during AMI and worse short- and long-term outcomes
One potential explanation may be that bleeding during the AMI hospitalization reduces the patient’s subsequent likelihood of receiving secondary prevention antiplatelet therapies after hospital discharge

3. Methods Bleeding No Bleeding Total AMI Population in PREMIER Registry
In-hospital bleeding or transfusion?
(TIMI major/minor bleeding or
non-CABG transfusion with baseline Hct ≥28)
yes no
Bleeding
N = 301
No Bleeding
N = 2,197
Patient Follow-up
1 month
6 months
1 year

4. Baseline characteristics P-value
No Bleeding
N = 2,197
Bleeding
N = 301
Baseline characteristics
P-value
Age (yrs)
60.3 ± 12.8
65.1 ± 13.7
<.001
Women (%)
31.1
43.2
Hypertension (%)
62.7
70.4
.01
Diabetes mellitus (%)
28.7
29.6
.76
Prior MI (%)
21.4
22.3
.73
Prior PCI (%)
17.8
18.9
.62
Prior CABG (%)
13.0
12.6
.87
Prior CHF (%)
11.2
18.3
Baseline CrCl (mg/dL)
74.4 ± 29.8
65.6 ± 40.4
In-hospital cath
87.2
85.4
.39
In-hospital PCI
61.3
57.8
.24
In-hospital CABG
11.4
12.0
.79
In-hospital procedures

5. Adjusted Discharge Medication Use
Adjusted OR †
95% CI
Discharge
0.45
0.31 –
0.64
Aspirin
1 month
0.68
0.50 –
0.92
6 months
0.63
0.46 –
0.87
1 year
0.94
0.66 –
1.34
Discharge
0.62
0.42 –
0.91
1 month
0.83
0.59 –
1.17
Thienopyridine
6 months
1.06
0.78 –
1.45
1 year
1.12
0.81 –
1.55
Discharge
0.76
0.54 –
1.08
1 month
1.05
0.76 –
1.44
Beta-blocker
6 months
1.09
0.79 –
1.51
1 year
0.87
0.63 –
1.20
Discharge
0.81
0.60 –
1.10
Statin
1 month
0.65
0.48 –
0.87
6 months
0.80
0.59 –
1.09
1 year
0.81
0.58 –
1.12 1 2
Less use
More use

6. Antiplatelet Use Stratified by Follow-up Type 1 month
Aspirin Use at 1 month
Thienopyridine Use at 1 month

7. Antiplatelet Use Stratified by Follow-up Type 6 months
Aspirin Use at 6 months
Thienopyridine Use at 6 months

8. Antiplatelet Use Stratified by Follow-up Type 12 months
Aspirin Use at 12 months
Thienopyridine Use at 12 months

9. Limitations
Small sample size limited power to assess how timing of antiplatelet medication resumption influences long- term outcomes
PREMIER did not capture detailed clinical rationale behind medication adjustments after discharge
Outpatient follow-up (type/intensity) was not pre- specified.
Observational analysis subject to unmeasured confounders despite multivariable adjustment

10. Conclusions
A significant proportion (12%) of patients with AMI experience bleeding complications or require non-CABG related transfusions during their AMI hospitalization
Patients who bleed are older and more likely to have comorbidities which can contribute to their worse long-term outcomes
Yet, another explanation for these worse outcomes might be that these patients are less aggressively treated with guidelines-recommended AMI therapies

11. Conclusions
In the setting of a recent bleed, post-AMI patients are less likely to be discharged on antiplatelet therapies such as aspirin or thienopyridines
Clinicians may defer re-initiation until “safe” from further bleeding
However, this treatment gaps persists even up to 6 months after the initial in-hospital event
Patients seen in follow-up by a cardiology specialist are more likely to be treated with antiplatelet agents than those seen in follow-up by a primary care practitioner or those with no clinical follow-up

12. Implications
While the decision to treat AMI patients with antiplatelet medications after bleeding is largely based on clinical intuition, continuity of care is critical as patients without post-discharge follow-up miss the opportunity to be evaluated for possible re-initiation of guidelines recommended secondary prevention therapies.
Clinicians should continuously reassess the opportunity to safely re-initiate these medications after resolution of the bleeding event.