Manoukian et al identified risk factors for major bleeding in a patient being treated for an acute coronary syndrome (ACS). The presence of major bleeding is an independent risk factors for 30-day mortality. The authors are from multiple hospitals from around the world.


Patient selection: ACS managed invasively with angiography and/or percutaneous coronary intervention


Criteria for major bleed not associated with a CABG procedure:

(1) intracranial hemorrhage

(2) intraocular bleed

(3) bleeding at an access site requiring an intervention

(4) hematoma >= 5 cm in diameter

(5) drop in hemoglobin >= 3 g/dL with known source

(6) drop in hemoglobin >= 4 g/dL with an occult source

(7) reoperation for bleeding

(8) need for blood product transfusion


Risk factors for a major bleed:

(1) age >= 75 years

(2) female gender

(3) diabetes mellitus

(4) hypertension

(5) renal insufficiency (creatinine clearance < 60 mL/min by the Cockcroft-Gault equation)

(6) anemia (baseline hemoglobin < 12 g/dL in a woman and < 13 g/dL in a man)

(7) no previous history of a percutaneous coronary intervention

(8) elevation of cardiac biomarkers

(9) ST segment deviation >= 1 mm

(10) therapy with heparin plus a glycoprotein IIb/IIIa inhibitor (GPI) (versus monotherapy with bivalrudin)



• The odd ratios for the risk factors range from 1.2 to 1.95.

• The risk factors with odd ratios > 1.6: age, gender, anemia, anticoagulant


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