Acute Myocardial Infarction Following Hospitalization for Gastrointestinal Bleeding: Incidence, Predictors, Management, and Outcomes

  • Gregory D. Rubinfeld
    Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Conn
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  • Jeffrey S. Berger
    Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, NY

    Department of Surgery, New York University School of Medicine, New York, NY
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  • Nathaniel R. Smilowitz
    Requests for reprints should be addressed to Nathaniel Smilowitz, MD, MS, Assistant Professor of Medicine, The Leon H. Charney Division of Cardiology, NYU Langone Health, NYU School of Medicine, 423 East 23rd Street, Room 12020-W, New York, NY, 10010.
    Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, NY

    Cardiology Section, Department of Medicine, Veterans Affairs New York Harbor Health Care System, New York, NY
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      Clinical characteristics of patients with acute myocardial infarction after gastrointestinal bleeding are poorly characterized. We sought to evaluate the incidence, management and outcomes of myocardial infarction following hospitalization for gastrointestinal bleeding.


      Patients admitted with a diagnosis of gastrointestinal bleeding with and without subsequent hospital readmissions for acute myocardial infarction within 90 days were identified in the 2014 U.S. Nationwide Readmission Database. Patients with myocardial infarction with and without a recent prior gastrointestinal bleed were compared to determine differences in management and in-hospital outcomes. Logistic regression models were used to estimate odds of invasive management and all-cause in-hospital mortality after covariate adjustment.


      A total of 644,622 patients with gastrointestinal bleeding were identified, of which 7523 (1.2%) were readmitted for myocardial infarction within 90 days. Compared to patients with myocardial infarction without recent gastrointestinal bleeding, patients with myocardial infarction within 90 days after gastrointestinal bleeding were older, more likely to be women, have kidney disease, presented with non-ST segment elevation myocarsdial infarction, and were less likely to undergo invasive management of acute myocardial infarction (28% vs 63%, P < .01). Prior gastrointestinal bleeding was associated with higher all-cause in-hospital myocardial infarction mortality (22% vs 9%, P < .01).


      In the first 3 months after hospitalization for gastrointestinal bleeding, 1 of every 83 patients was readmitted with acute myocardial infarction. Patients with myocardial infarction after gastrointestinal bleeding were less likely to undergo invasive management and coronary revascularization and had higher mortality than those without recent bleeding.


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        • Stephan B
        • Schenk JF
        • Pindur G
        • et al.
        Influence of bleeding on haemorheology and haemostasis in surgery.
        Clin Hemorheol Microcirc. 2010; 46: 183-188
        • Campbell CL
        • Steinhubl SR
        • Hooper WC
        • et al.
        Bleeding events are associated with an increase in markers of inflammation in acute coronary syndromes: an ACUITY trial substudy.
        J Thromb Thrombolysis. 2011; 31: 139-145
        • Held C
        • Hylek EM
        • Alexander JH
        • et al.
        Clinical outcomes and management associated with major bleeding in patients with atrial fibrillation treated with apixaban or warfarin: insights from the ARISTOTLE trial.
        Eur Heart J. 2015; 36: 1264-1272
        • Wu CJ
        • Lin HJ
        • Weng SF
        • et al.
        Acute myocardial infarction risk in patients with coronary artery disease doubled after upper gastrointestinal tract bleeding: a nationwide nested case-control study.
        PLoS One. 2015; 10e0142000
        • Levine GN
        • Bates ER
        • Bittl JA
        • et al.
        2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines.
        J Am Coll Cardiol. 2016; 68: 1082-1115
        • Urban P
        • Mehran R
        • Colleran R
        • et al.
        Defining high bleeding risk in patients undergoing percutaneous coronary intervention: a consensus document from the Academic Research Consortium for High Bleeding Risk.
        Eur Heart J. 2019; 40: 2632-2653
        • Roy P
        • Bonello L
        • Torguson R
        • et al.
        Impact of “nuisance” bleeding on clopidogrel compliance in patients undergoing intracoronary drug-eluting stent implantation.
        Am J Cardiol. 2008; 102: 1614-1617
        • Valgimigli M
        • Patialiakas A
        • Thury A
        • et al.
        Zotarolimus-eluting versus bare-metal stents in uncertain drug-eluting stent candidates.
        J Am Coll Cardiol. 2015; 65: 805-815
        • Urban P
        • Meredith IT
        • Abizaid A
        • et al.
        Polymer-free drug-coated coronary stents in patients at high bleeding risk.
        N Engl J Med. 2015; 373: 2038-2047
        • Mehran R
        • Chandrasekhar J
        • Urban P
        • et al.
        Sex-based outcomes in patients with a high bleeding risk after percutaneous coronary intervention and 1-month dual antiplatelet therapy: a secondary analysis of the LEADERS FREE randomized clinical trial.
        JAMA Cardiol. 2020; 5: 939-947
        • Steiner C
        • Elixhauser A
        • Schnaier J.
        The healthcare cost and utilization project: an overview.
        Eff Clin Pract. 2002; 5: 143-151
        • Selak V
        • Kerr A
        • Poppe K
        • et al.
        Annual risk of major bleeding among persons without cardiovascular disease not receiving antiplatelet therapy.
        JAMA. 2018; 319: 2507-2520
        • Smilowitz NR
        • Gupta N
        • Guo Y
        • Berger JS
        • Bangalore S.
        Perioperative acute myocardial infarction associated with non-cardiac surgery.
        Eur Heart J. 2017; 38: 2409-2417
        • Elixhauser A
        • Steiner C
        • Harris DR
        • Coffey RM.
        Comorbidity measures for use with administrative data.
        Med Care. 1998; 36: 8-27
        • Smilowitz NR
        • Gupta N
        • Ramakrishna H
        • Guo Y
        • Berger JS
        • Bangalore S.
        perioperative major adverse cardiovascular and cerebrovascular events associated with noncardiac surgery.
        JAMA Cardiol. 2017; 2: 181-187
        • Brinjikji W
        • Rabinstein AA
        • Kallmes DF
        • Cloft HJ.
        Patient outcomes with endovascular embolectomy therapy for acute ischemic stroke: a study of the national inpatient sample: 2006 to 2008.
        Stroke. 2011; 42: 1648-1652
        • Vallabhajosyula S
        • Kashani K
        • Dunlay SM
        • et al.
        Acute respiratory failure and mechanical ventilation in cardiogenic shock complicating acute myocardial infarction in the USA, 2000-2014.
        Ann Intensive Care. 2019; 9: 96
        • Mehran R
        • Pocock S
        • Nikolsky E
        • et al.
        Impact of bleeding on mortality after percutaneous coronary intervention results from a patient-level pooled analysis of the REPLACE-2 (randomized evaluation of PCI linking angiomax to reduced clinical events), ACUITY (acute catheterization and urgent intervention triage strategy), and HORIZONS-AMI (harmonizing outcomes with revascularization and stents in acute myocardial infarction) trials.
        JACC Cardiovasc Interv. 2011; 4: 654-664
        • Gupta K
        • Khan A
        • Kumar M
        • Sawalha K
        • Abozenah M
        • Singhania R.
        Readmissions rates after myocardial infarction for gastrointestinal bleeding: a national perspective.
        Dig Dis Sci. 2021; 66: 751-759
        • Nikolsky E
        • Stone GW
        • Kirtane AJ
        • et al.
        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
        • Moukarbel GV
        • Signorovitch JE
        • Pfeffer MA
        • et al.
        Gastrointestinal bleeding in high risk survivors of myocardial infarction: the VALIANT Trial.
        Eur Heart J. 2009; 30: 2226-2232
        • Chan FK
        • Leung Ki EL
        • Wong GL
        • et al.
        Risks of bleeding recurrence and cardiovascular events with continued aspirin use after lower gastrointestinal hemorrhage.
        Gastroenterology. 2016; 151: 271-277
        • Sung JJ
        • Lau JY
        • Ching JY
        • et al.
        Continuation of low-dose aspirin therapy in peptic ulcer bleeding: a randomized trial.
        Ann Intern Med. 2010; 152: 1-9
        • Tomaselli GF
        • Mahaffey KW
        • Cuker A
        • et al.
        2020 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants: A Report of the American College of Cardiology solution set oversight committee.
        J Am Coll Cardiol. 2020; 76: 594-622
        • Rubinfeld GD
        • Smilowitz NR
        • Berger JS
        • Newman JD.
        Association of thrombocytopenia, revascularization, and in-hospital outcomes in patients with acute myocardial infarction.
        Am J Med. 2019; 132: 942-948.e5
        • Vranckx P
        • Valgimigli M
        • Juni P
        • et al.
        Ticagrelor plus aspirin for 1 month, followed by ticagrelor monotherapy for 23 months vs aspirin plus clopidogrel or ticagrelor for 12 months, followed by aspirin monotherapy for 12 months after implantation of a drug-eluting stent: a multicentre, open-label, randomised superiority trial.
        Lancet. 2018; 392: 940-949
        • Mehran R
        • Baber U
        • Sharma SK
        • et al.
        Ticagrelor with or without aspirin in high-risk patients after PCI.
        N Engl J Med. 2019; 381: 2032-2042
        • Watanabe H
        • Domei T
        • Morimoto T
        • et al.
        Effect of 1-month dual antiplatelet therapy followed by clopidogrel vs 12-month dual antiplatelet therapy on cardiovascular and bleeding events in patients receiving PCI: The STOPDAPT-2 randomized clinical trial.
        JAMA. 2019; 321: 2414-2427
        • Freedberg DE
        • Kim LS
        • Yang YX.
        The risks and benefits of long-term use of proton pump inhibitors: expert review and best practice advice from the American Gastroenterological Association.
        Gastroenterology. 2017; 152: 706-715