Mortality after Bleeding versus Myocardial Infarction in Coronary Artery Disease: A Systematic Review and Meta-Analysis.

Background Bleeding is the principal safety concern of antithrombotic therapy and occurs frequently among patients with coronary artery disease (CAD). Aims We aim to evaluate the prognostic impact of bleeding on mortality compared with that of myocardial infarction (MI) in patients with CAD. Methods We searched Medline and Embase for studies that included patients with CAD and that reported both, the association between the occurrence of bleeding and mortality, and between the occurrence of MI and mortality within the same population. Adjusted hazard ratios (HRs) for mortality associated with bleeding and MI were extracted and ratio of hazard ratios (rHRs) were pooled by using inverse variance weighted random effects meta-analyses. Early events included periprocedural or within 30-day events after revascularization or acute coronary syndrome (ACS). Late events included spontaneous or beyond 30-day events after revascularization or ACS. Results 141,059 patients were included across 16 studies and 128,660 (91%) underwent percutaneous coronary intervention. Major bleeding, increased the risk of mortality to the same extent of MI (rHRbleedingvs.MI 1.10, 95%CI, 0.71-1.71, P=0.668). Early bleeding was associated with a higher risk of mortality than early MI (rHRbleedingvs.MI 1.46, 95%CI, 1.13-1.89, P=0.004), although this finding was not present when only randomized trials were included. Late bleeding was prognostically comparable to late MI (rHRbleedingvs.MI 1.14, 95%CI, 0.87-1.49, P=0.358). Conclusions Compared with MI, major and late bleeding is associated with a similar increase in mortality, whereas early bleeding might have a stronger association with mortality.