Preventing bleeding is key to the treatment of acute coronary syndromes

On Monday, September 4 and Tuesday, September 5 at the World Congress of Cardiology, Dr. Christopher Granger presented data stressing the importance of prevention of bleeding as a key objective in treatment of acute coronary syndromes.

He concluded that not only is it important to prevent blood clots and recurrent heart attacks in patients presenting with acute coronary syndromes, but it may be equally important to prevent bleeding. This is a new concept. Several studies have now shown that bleeding appears to increase mortality about as much as a heart attack. Bleeding is also common – in fact, one US registry (CRUSADE) recently found that 15% of patients hospitalized for acute coronary syndrome were given a blood transfusion. Blood transfusion, touted by the American Red Cross as "the gift of life," may be part of the problem, since it appears to be a double-edged sword with some negative effects. It may be that blood transfusions should be limited to patients who more clearly need them.

Recent trials have shown that two anticoagulant drugs – bivalirudin and fondaparinux – can both reduce the risk of bleeding in some situations. The 20,000 patient OASIS-5 trial found that fondaparinux, compared to another anticoagulant enoxaparin, is just as effective at preventing clot-related events but only caused half the bleeding. This finding was consistent whether or not patients also received heparin. That reduction of bleeding was followed by a significant 17% relative risk reduction in death at 30 days.

"Bleeding is common, it is lethal, and it is preventable," Dr. Granger stated. "We now have treatments available – like the blood-thinner fondaparinux – that are effective at preventing blood clots but have a 50% lower risk of bleeding, and that ends up saving lives."

Although it is not clear why bleeding increases mortality weeks and months later, it may relate both to the stress of the bleeding episode and to the physicians' response, including discontinuation of blood thinners that may be important for the long term prevention of further blood clotting.

Other ways to reduce bleeding include more careful use of all blood thinners. One study from the CRUSADE registry showed that over 40% of American patients are being overdosed by one or more drugs, especially the elderly and patients with renal insufficiency who are at high risk for bleeding.

We now know that treatments that prevent bleeding can improve survival. This finding creates a new paradigm for management of ACS, which not only focuses on prevention of thrombosis, but equally importantly on minimizing bleeding risk.