Early Guideline-Directed Medical Therapy and In-Hospital Major Bleeding Risk in ST-Elevation Myocardial Infarction Patients Treated with Percutaneous Coronary Intervention: Findings from the CCC-ACS Project

Abstract

BACKGROUNDPrevious reports demonstrated a bleeding avoidance potential of angiotensin converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB) and β-blocker. It remains unclear whether guideline-directed medical therapy [GDMT, i.e., the combined use of β-blocker, angiotensin converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB) and statin] confers protection against bleeding in the setting of high-intensity antithrombotic therapy.METHODSWe assessed associations between the use of early (within the first 24 hours) GDMT and in-hospital major bleeds, ischemic events and mortality among ST-elevation myocardial infarction (STEMI) patients treated with percutaneous coronary intervention (PCI) in the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome project.RESULTSAmong 34,538 STEMI patients without contra-indications to GDMT and eligible for analysis, 35.5% received early GDMT. In a 1-to-2 propensity-score matched cohort, early GDMT was associated with a 28% reduction in major bleeds [odds ratio (OR): 0.72, 95% confidence interval (CI): 0.58 to 0.90], with parallel reductions in ischemic events (OR: 0.60, 95% CI: 0.46 to 0.78) and in-hospital mortality (OR: 0.41, 95% CI: 0.30 to 0.57). GDMT-associated reduction in major bleeds was consistently observed across different major bleeding definitions and in sensitivity analyses. Additionally, no significant interaction was observed in subgroup analyses. CONCLUSIONSIn a large nationwide registry, early initiation of GDMT was associated with reduced risk for in-hospital major bleeds in STEMI patients treated with PCI. To improve the outcome of STEMI, further effort should be made to reinforce the use of GDMT in this patient population.