Incidence, source, determinants, and prognostic impact of major bleeding in outpatients with stable coronary artery disease.

BACKGROUND: Although there is evidence that patients who experience major bleeding after an acute coronary event are at higher risk of death in the months after the event, the incidence and impact on outcome of bleeding beyond 1 year of follow-up in patients with stable coronary artery disease (CAD) are largely unknown. OBJECTIVES: The goal of this study was to assess the incidence, source, determinants, and prognostic impact of major bleeding in stable CAD. METHODS: We prospectively included 4,184 consecutive CAD outpatients who were free from any myocardial infarction (MI) or coronary revascularization for >1 year at inclusion. Follow-up was performed at 2 years, with major bleeding defined as a type ≥3 bleed using the Bleeding Academic Research Consortium (BARC) definition. RESULTS: There were 51 major bleeding events during follow-up (0.6%/year). Most events were BARC type 3a bleeds with 12 fatal bleeds (type 5). In most cases (54.9%), the site of bleeding was gastrointestinal. Major bleeding was significantly associated with mortality (adjusted hazard ratio: 2.89; 95% confidence intervals: 1.73 to 4.83; p < 0.0001). The increased risk of bleeding associated with vitamin K antagonist (VKA) treatment was particularly evident when VKA was combined with an antiplatelet therapy (APT). In contrast, the risk of cardiovascular death, MI, or nonhemorrhagic stroke did not differ in patients who received VKA + APT versus patients on VKA alone. CONCLUSIONS: In patients with stable CAD (i.e., >1 year, with no acute events), major bleeding events are rare, but such events are an independent predictor of death. When oral anticoagulation is required, concomitant APT should not be prescribed in the absence of a recent cardiovascular event.

Left ventricular remodeling is associated with the severity of mitral regurgitation after inaugural anterior myocardial infarction--optimal timing for echocardiographic imaging.

BACKGROUND: Although mitral regurgitation (MR) has been associated with an increased risk of death and heart failure after myocardial infarction (MI), the relationship between post-MI MR and left ventricular (LV) remodeling has not been entirely clarified. In addition, the optimal timing for assessing MR after MI remains unknown. METHODS: Post-MI MR was assessed by Doppler echocardiography at hospital discharge (baseline) and after 3 months in 261 patients with an inaugural anterior MI. We studied LV remodeling during a 1-year period and clinical follow-up after 3 years, according to MR severity at baseline and at 3 months. RESULTS: Left ventricular remodeling was demonstrated as an increase in LV end-diastolic volume from 56 +/- 15 mL/m(2) at baseline to 63 +/- 19 mL/m(2) at 1 year (P < .0001). MR severity at baseline was not significantly associated with LV remodeling. By contrast, MR severity at 3 months was a strong indicator of LV remodeling. There was a graded increase in the proportion of patients with a >20% increase in LV end-diastolic volume between baseline and 1 year according to MR severity at 3 months (no MR: 21%, mild MR: 32%, moderate/severe MR: 60%) (P = .008). Both MR at baseline and at 3 months were associated with death or rehospitalization for heart failure by univariate analysis (P = .014 and P < .0001, respectively). By multivariable analysis, MR at baseline was not an independent predictor of adverse outcome (P = .66). By contrast, MR at 3 months was independently associated with adverse outcome with a hazard ratio of 2.23 (1.02-4.91 [P = .04]). CONCLUSIONS: After an inaugural anterior MI, MR is associated with LV remodeling and adverse clinical outcome. For prognostic purpose, the optimal timing for assessing MR is the chronic post-MI stage rather than the early post-MI period.