Women, bleeding, and coronary intervention.

B leeding initiates a cascade of events that increase morbidity and mortality among patients undergoing percu-taneous coronary intervention (PCI). Acute loss of blood impacts circulatory volume and can potentiate and perpetuate shock. In addition, bleeding leads to anemia and transfusion of blood products, which promote inflammation and untoward cardiovascular effects, especially in the setting of acute coronary syndrome. 6–8 Finally, bleeding results in cessation of dual antiplatelet therapy, which increases risk of recurrent ischemic events such as stent thrombosis and myocardial infarction. Registries and randomized trials have shown the impact of bleeding on outcomes. Patient in the Global Registry of Acute Coronary Events were noted to have a 4.0% incidence of major bleeding across the spectrum of acute coronary syndrome (ACS). Furthermore, major bleeding was an independent pre-dictor of in-hospital mortality (adjusted odds ratio, 1.64 [95% confidence interval, 1.18-2.28]). 11 Ndrepepa et al 2 evaluated 4 randomized control trials of patients undergoing PCI and identified major bleeding as the strongest independent predic-tor of 1-year mortality. Similarly, Mehran et al 12 performed a patient level pooled analysis of >17 000 patients in 3 ACS trials: the occurrence of a major bleed within 30 days of hospitalization was associated with a 4-fold higher risk of mortality at 1 year. Finally, in patients with ST segment elevation myo-cardial infarction enrolled in the Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction trial, bleeding related to PCI was an independent predictor of mortality after 3 years of follow-up (hazard ratio, 2.80 [95% confidence interval, 1.89–4.16]). 13 Increased focus on the morbidity and mortality associated with PCI-related bleeding has led to pharmacological, procedural , and technological advances, 14 which have resulted in improvement in post-PCI bleeding rates over the past decade (Figure 1). The 2011 American College of Cardiology-American Heart Association PCI Guidelines formally recognize the quality improvement goal of reducing bleeding complications: " All patients should be evaluated for risk of bleeding complications before PCI " (class I, level of evidence C). 19 Absolute event rates for bleeding have improved over time for both men and women undergoing PCI and, as reviewed below, major bleeding occurs in <3% of both sexes. In this Review article, we highlight the risk of bleeding complications in women compared with men, the differences in platelet biology and potential ischemic risk, and the guideline-recommended pharmacology that may benefit women undergoing coronary intervention. Ongoing quality improvement focuses on prevention …