Bleeding characteristics and mortality outcomes following ST-elevation myocardial infarction thrombolysis: a 5-year analysis in an Asian population

doi:10.5847/wjem.j.1920-8642.2024.077

Abstract

Abstract:

BACKGROUND: Bleeding outcomes are crucial primary safety endpoints in studies involving thrombolytic agents. This study aimed to determine the incidence, characteristics and mortality outcomes of bleeding following ST-elevation myocardial infarction (STEMI) thrombolysis in an Asian population.

METHODS: This single-centre retrospective study included all STEMI patients who received thrombolytic therapy from 2016 to 2020 in a Malaysian tertiary hospital. Total population sampling was used in this study. The primary outcome was bleeding events post-thrombolysis, categorised using the Thrombolysis in Myocardial Infarction (TIMI) bleeding criteria. Inferential statistics were used to determine the associations between relevant variables.

RESULTS: Data from 941 patients were analysed. A total of 156 (16.6%) STEMI patients bled post-thrombolysis. Major, minor, and minimal TIMI occurred in 7 (0.7%), 17 (1.8%), and 132 (14.0%) patients, respectively. Age 65 years (P=0.031) and Malaysian Chinese (P=0.008) were associated with a higher incidence of bleeding post-thrombolysis. Conversely, foreigners (P=0.032) and current smoker (P=0.007) were associated with a lower incidence of bleeding. Both TIMI major (P<0.001) and TIMI minor (P<0.001) were associated with a higher incidence of all-cause in-hospital mortality among STEMI patients. TIMI minor bleeding was significantly higher in the streptokinase recipients. The bleeding sites were comparable between streptokinase and tenecteplase recipients, except for a significantly higher incidence of gastrointestinal bleeding in the streptokinase recipients (P=0.027).

CONCLUSION: In our Asian population, the incidence of total bleeding events following STEMI thrombolysis is comparable to that previously reported. The development of TIMI major and minor bleeding complications is associated with higher mortality.

Key words: Bleeding, ST-elevation myocardial infarction thrombolysis, Asian, Tenecteplase, Streptokinase

Hock Peng Koh, Jivanraj R. Nagarajah, Hasnita Hassan, Noel Thomas Ross. Bleeding characteristics and mortality outcomes following ST-elevation myocardial infarction thrombolysis: a 5-year analysis in an Asian population[J]. World Journal of Emergency Medicine, 2024, 15(6): 433-440.

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References 33

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Characteristics	No bleeding (n=785)	Bleeding (n=156)	P-value
Age, years, mean ± SD	52.4±12.3	55.8±11.6	0.161 ^a
Age ≥ 65 years, n (%)	121 (15.4)	35 (22.4)	0.031 ^b
Male, n (%)	708 (90.2)	138 (88.5)	0.513 ^b
Malaysian Malay, n (%)	271 (34.5)	59 (37.8)	0.430 ^b
Malaysian Chinese, n (%)	63 (8.0)	23 (14.7)	0.008 ^b
Malaysian Indian, n (%)	160 (20.4)	33 (21.2)	0.827 ^b
Permanent residents, n (%)^*	80 (10.2)	13 (8.3)	0.478 ^b
Foreigners, n (%)^#	199 (25.4)	27 (17.3)	0.032 ^b
Hypertension, n (%)	351 (44.7)	81 (51.9)	0.099 ^b
Diabetes, n (%)	282 (35.9)	67 (42.9)	0.097 ^b
Ischemic stroke, n (%)	14 (1.8)	7 (4.5)	0.066 ^c
Ischemic heart disease, n (%)	114 (14.5)	28 (17.9)	0.275 ^b
History of PCI, n (%)	12 (1.5)	4 (2.6)	0.320 ^c
History of CABG, n (%)	5 (0.6)	0 (0.0)	1.000 ^c
Heart failure, n (%)	20 (2.5)	2 (1.3)	0.560 ^c
Tenecteplase use, n (%)	393 (50.1)	67 (42.9)	0.104 ^b
Streptokinase use, n (%)	392 (49.9)	89 (57.1)	0.104 ^b
Current smoker, n (%)	550 (70.1)	92 (59.0)	0.007 ^b
Positive family history of IHD, n (%)	154 (19.6)	34 (21.8)	0.535^b

Bleeding characteristics	All (n=941)	Survived (n=844)	Died (n=97)	P-value
Intracranial hemorrhage	4 (0.4)	0 (0.0)	4 (4.1)	<0.001^a
TIMI major bleeding^*	7 (0.7)	2 (0.2)	5 (5.2)	<0.001^a
TIMI minor bleeding	17 (1.8)	9 (1.1)	8 (8.2)	<0.001^a
TIMI minimal bleeding	132 (14.0)	122 (14.5)	10 (10.3)	0.265 ^b
All bleeding	156 (16.6)	133 (15.8)	23 (23.7)	0.046 ^b

Characteristics	Streptokinase (n=481)	Tenecteplase (n=460)	P-value
Any bleeding	89 (18.5)	67 (14.6)	0.104 ^a
TIMI bleeding
Major	4 (0.8)	3 (0.7)
Minor	14 (2.9)	3 (0.7)
Minimal	71 (14.8)	61 (13.3)
Type/site of bleeding
Intracranial hemorrhage	3 (0.6)	1 (0.2)	0.625 ^b
Gastrointestinal bleeding	17 (3.5)	6 (1.3)	0.027 ^a
Intraabdominal bleeding	1 (0.2)	0 (0.0)	1.000 ^b
Hematuria	8 (1.7)	13 (2.8)	0.227 ^a
Hematoma	6 (1.2)	3 (0.7)	0.507 ^b
Bleeding from the oral cavity	56 (11.6)	37 (8.0)	0.064 ^a
Subconjunctival/vitreous hemorrhage	1 (0.2)	1 (0.2)	1.000 ^b
Epistaxis	1 (0.2)	0 (0.0)	1.000 ^b
Hemoptysis	5 (1.0)	5 (1.1)	1.000 ^b
Endotracheal bleeding	1 (0.2)	2 (0.4)	0.616 ^b
Otorrhagia	0 (0.0)	1 (0.2)	0.489 ^b
Bleeding from the cannula site	0 (0.0)	1 (0.2)	0.489 ^b

Events	Pre-COVID-19 pandemic (n=794)	COVID-19 pandemic^#(n=147)	P-value
Achieved door-to-needle time of ≤30 min	598 (75.3)	103 (70.1)	0.136 ^a
In-hospital mortality	75 (9.4)	23 (15.6)	0.026 ^a
TIMI major bleeding^*	7 (0.9)	0 (0.0)	0.604 ^b
TIMI minor bleeding	14 (1.8)	3 (2.0)	0.740 ^b
TIMI minimal bleeding	120 (15.1)	12 (8.2)	0.024^a