Incidence, Predictors, and Outcomes of Gastrointestinal Bleeding in Patients Admitted With ST-Elevation Myocardial Infarction

      Gastrointestinal bleeding (GIB) complicating ST-elevation myocardial infarction (STEMI) poses significant management challenges and may be associated with poor outcomes. We sought to evaluate the incidence and outcomes of GIB in STEMI patients using a nationwide database. We identified adults admitted with STEMI between in the National Inpatient Sample (2003 to 2016), and compared the morbidity, mortality, resource utilization, and cost in patients with and without GIB. We assessed rates of endoscopy referral and its associated with mortality. Among 1,450,696 weighted STEMI hospitalizations, 32,624 (2.2%) were complicated with GIB. Patients with GIB were older, and had distinctive characteristics compared to those without GIB. Older age, cardiogenic shock; history of peptic ulcer disease, cirrhosis, anemia, or alcohol use disorder were the strongest predictors of GIB during STEMI hospitalizations. In-hospital mortality was higher in the GIB group (28.2% vs 11.1%, p <0.001). The excess mortality associated with GIB persisted after propensity-score matching, and in sensitivity analyses excluding patients who underwent coronary intervention >24-hours after admission, and those transferred to another hospital. Post-STEMI GIB was associated with more strokes and acute kidney injury, longer hospitalizations, and higher cost. In a logistic regression analysis, GIB was independently associated with mortality (odds ratios [OR] 1.91, 95% confidence interval [CI] 1.85 to 1.97, p <0.001). There was a correlation between undergoing endoscopy and lower in-hospital mortality (unadjusted OR 0.27; 95% CI, 0.24 to 0.29; adjusted-OR 0.30; 95% CI, 0.27 to 0.33; p <0.001). In conclusion, GIB complicating STEMI is uncommon but is associated with excess morbidity, mortality, resource utilization and cost. Referral to endoscopy in this cohort may be associated with reduced in-hospital mortality.
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        • van Leerdam ME
        Epidemiology of acute upper gastrointestinal bleeding.
        Best Pract Res Clin Gastroenterol. 2008; 22: 209-224
        • Wuerth BA
        • Rockey DC
        Changing epidemiology of upper gastrointestinal hemorrhage in the last decade: a nationwide analysis.
        Dig Dis Sci. 2018; 63: 1286-1293
        • Yachimski P
        • Hur C
        Upper endoscopy in patients with acute myocardial infarction and upper gastrointestinal bleeding: results of a decision analysis.
        Dig Dis Sci. 2009; 54: 701-711
        • Mumtaz K
        • Ismail FW
        • Jafri W
        • Abid S
        • Hamid S
        • Shah H
        • Dhakam S
        Safety and utility of oesophago-gastro-duodenoscopy in acute myocardial infarction.
        Eur J Gastroenterol Hepatol. 2008; 20: 51-55
        • Lichtman JH
        • Spertus JA
        • Reid KJ
        • Radford MJ
        • Rumsfeld JS
        • Allen NB
        • Masoudi FA
        • Weintraub WS
        • Krumholz HM
        Acute noncardiac conditions and in-hospital mortality in patients with acute myocardial infarction.
        Circulation. 2007; 116: 1925-1930
        • Yang QY
        • Ouyang J
        • Yang JD
        Sepsis as an important risk factor for gastrointestinal bleeding in acute coronary syndrome patients: two case reports.
        Medicine (Baltimore). 2018; 97: e12273
        • Leonor P
        • Sahakian AB
        Gastrointestinal hemorrhage in patients with acute ischemic stroke: should endoscopy be within the scope of practice?.
        Dig Dis Sci. 2019; 64: 1395-1396
        • Patel NJ
        • Pau D
        • Nalluri N
        • Bhatt P
        • Thakkar B
        • Kanotra R
        • Agnihotri K
        • Ainani N
        • Patel N
        • Patel N
        • Shah S
        • Kadavath S
        • Arora S
        • Sheikh A
        • Badheka AO
        • Lafferty J
        • Alfonso C
        • Cohen M
        Temporal trends, predictors, and outcomes of in-hospital gastrointestinal bleeding associated with percutaneous coronary intervention.
        Am J Cardiol. 2016; 118: 1150-1157
        • Nash MC
        • Strom JA
        • Pathak EB
        Prevalence of major infections and adverse outcomes among hospitalized. ST-elevation myocardial infarction patients in Florida, 2006.
        BMC Cardiovasc Disord. 2011; 11: 69
        • Issa M
        • Alqahtani F
        • Berzingi C
        • Al-Hajji M
        • Busu T
        • Alkhouli M
        Impact of acute diabetes decompensation on outcomes of diabetic patients admitted with ST-elevation myocardial infarction.
        Diabetol Metab Syndr. 2018; 10: 57
        • Nikolsky E
        • Stone GW
        • Kirtane AJ
        • Dangas GD
        • Lansky AJ
        • McLaurin B
        • Lincoff AM
        • Feit F
        • Moses JW
        • Fahy M
        • Manoukian SV
        • White HD
        • Ohman EM
        • Bertrand ME
        • Cox DA
        • Mehran R
        Gastrointestinal bleeding in patients with acute coronary syndromes: incidence, predictors, and clinical implications: analysis from the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial.
        J Am Coll Cardiol. 2009; 54: 1293-1302
        • Shivaraju A
        • Patel V
        • Fonarow GC
        • Xie H
        • Shroff AR
        • Vidovich MI
        Temporal trends in gastrointestinal bleeding associated with percutaneous coronary intervention: analysis of the 1998-2006 nationwide inpatient sample (NIS) database.
        Am Heart J. 2011; 162: 1062-1068.e1065
        • Kinnaird TD
        • Stabile E
        • Mintz GS
        • Lee CW
        • Canos DA
        • Gevorkian N
        • Pinnow EE
        • Kent KM
        • Pichard AD
        • Satler LF
        • Weissman NJ
        • Lindsay J
        • Fuchs S
        Incidence, predictors, and prognostic implications of bleeding and blood transfusion following percutaneous coronary interventions.
        Am J Cardiol. 2003; 92: 930-935
        • Ng FH
        • Wong SY
        • Lam KF
        • Chang CM
        • Lau YK
        • Chu WM
        • Wong BC
        Gastrointestinal bleeding in patients receiving a combination of aspirin, clopidogrel, and enoxaparin in acute coronary syndrome.
        Am J Gastroenterol. 2008; 103: 865-871
        • Kikkert WJ
        • Hassell ME
        • Delewi R
        • van der Laan MH
        • Baan Jr., J
        • Vis MM
        • Koch KT
        • de Winter RJ
        • Piek JJ
        • Tijssen JG
        • Henriques JP
        Predictors and prognostic consequence of gastrointestinal bleeding in patients with ST-segment elevation myocardial infarction.
        Int J Cardiol. 2015; 184: 128-134
        • Szummer K
        • Wallentin L
        • Lindhagen L
        • Alfredsson J
        • Erlinge D
        • Held C
        • James S
        • Kellerth T
        • Lindahl B
        • Ravn-Fischer A
        • Rydberg E
        • Yndigegn T
        • Jernberg T
        Improved outcomes in patients with ST-elevation myocardial infarction during the last 20 years are related to implementation of evidence-based treatments: experiences from the SWEDEHEART registry 1995-2014.
        Eur Heart J. 2017; 38: 3056-3065
        • He L
        • Zhang J
        • Zhang S
        Risk factors of in-hospital mortality among patients with upper gastrointestinal bleeding and acute myocardial infarction.
        Saudi J Gastroenterol. 2018; 24: 177-182
        • Lee CH
        • Cheng CL
        • Kao Yang YH
        • Chao TH
        • Chen JY
        • Li YH
        Cardiovascular and bleeding risks in acute myocardial infarction newly treated with ticagrelor vs. clopidogrel in Taiwan.
        Circ J. 2018; 82: 747-756
        • Pellaton C
        • Cayla G
        • Silvain J
        • Zeymer U
        • Cohen M
        • Goldstein P
        • Huber K
        • Pollack Jr., C
        • Kerneis M
        • Collet JP
        • Vicaut E
        • Montalescot G
        • Investigators A
        Incidence and consequence of major bleeding in primary percutaneous intervention for ST-elevation myocardial infarction in the era of radial access: an analysis of the international randomized acute myocardial infarction treated with primary angioplasty and intravenous enoxaparin or unfractionated heparin to lower ischemic and bleeding events at short- and Long-term follow-up trial.
        Am Heart J. 2015; 170: 778-786
        • Hamon M
        • Lemesle G
        • Tricot O
        • Meurice T
        • Deneve M
        • Dujardin X
        • Brufau JM
        • Bera J
        • Lamblin N
        • Bauters C
        Incidence, source, determinants, and prognostic impact of major bleeding in outpatients with stable coronary artery disease.
        J Am Coll Cardiol. 2014; 64: 1430-1436
        • Al-Mallah M
        • Bazari RN
        • Jankowski M
        • Hudson MP
        Predictors and outcomes associated with gastrointestinal bleeding in patients with acute coronary syndromes.
        J Thromb Thrombolysis. 2007; 23: 51-55
        • Dorreen A
        • Moosavi S
        • Martel M
        • Barkun AN
        Safety of digestive endoscopy following acute coronary syndrome: a systematic review.
        Can J Gastroenterol Hepatol. 2016; 20169564529
        • Siddiqui MT
        • Bilal M
        • Gollapudi LA
        • Mehta D
        • Umar S
        • Barsa J
        • Nabors C
        • Schorr-Lesnick B
        • Lebovics E
        • Tewari V
        Endoscopy is relatively safe in patients with acute ischemic stroke and gastrointestinal hemorrhage.
        Dig Dis Sci. 2018;
        • ASGE Standards of Practice Committee
        • Acosta RD
        • Abraham NS
        • Chandrasekhara V
        • Chathadi KV
        • Early DS
        • Eloubeidi MA
        • Evans JA
        • Faulx AL
        • Fisher DA
        • Fonkalsrud L
        • Hwang JH
        • Khashab MA
        • Lightdale JR
        • Muthusamy VR
        • Pasha SF
        • Saltzman JR
        • Shaukat A
        • Shergill AK
        • Wang A
        • Cash BD
        • DeWitt JM
        The management of antithrombotic agents for patients undergoing GI endoscopy.
        Gastrointest Endosc. 2016; 83: 3-16
        • Ibanez B
        • James S
        • Agewall S
        • Antunes MJ
        • Bucciarelli-Ducci C
        • Bueno H
        • Caforio ALP
        • Crea F
        • Goudevenos JA
        • Halvorsen S
        • Hindricks G
        • Kastrati A
        • Lenzen MJ
        • Prescott E
        • Roffi M
        • Valgimigli M
        • Varenhorst C
        • Vranckx P
        • Widimský P
        • ESC Scientific Document Group
        2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the task force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology.
        Eur Heart J. 2018; 39: 119-177
        • Barada K
        • Karrowni W
        • Abdallah M
        • Shamseddeen W
        • Sharara A
        • Kakik H
        Upper gastrointestinal bleeding in patients with acute coronary syndromes.
        J Clin Ga. 2008; 42: 368-372
        • Kiyota Y
        • Schneeweiss S
        • Glynn RJ
        • Cannuscio CC
        • Avorn J
        • Solomon DH
        Accuracy of medicare claims-based diagnosis of acute myocardial infarction: estimating positive predictive value on the basis of review of hospital records.
        Am Heart J. 2004; 148: 99-104
        • McCormick N
        • Lacaille D
        • Bhole V
        • Avina-Zubieta JA
        Validity of myocardial infarction diagnoses in administrative databases: a systematic review.
        PLoS One. 2014; 9: e92286