GI bleeding confers worse outcomes after TAVR
Among patients who underwent transcatheter aortic valve replacement, those with gastrointestinal bleeding were more likely to die in the hospital and had higher costs and longer length of stay, researchers reported.
The researchers also identified comorbidities that elevated risk for gastrointestinal (GI) bleeding after TAVR.
“We know that major bleeding remains one of the ‘Big 5’ complications after TAVR that were identified in the landmark PARTNER trial,” Salman Zahid, MD, internal medicine resident at Rochester General Hospital, New York, told Healio. “GI bleeding is a significant cause of major bleeding associated with significantly higher mortality and morbidity. It is also important to note that patients with peptic ulcer disease and upper GI bleeding in the last 3 months were excluded in the landmark PARTNER trial. Hence, we wanted to study in the real world using a national U.S. database, the trends, outcomes and predictors of GI bleeding after TAVR.”
Zahid and colleagues identified 216,023 hospitalizations for TAVR (median age, 82 years; 47% women) from 2011 to 2018 included in the National Inpatient Sample database. Among the cohort, 1% had GI bleeding.
The analysis was based on propensity matching between those who had GI bleeding and those who did not.
GI bleeding after TAVR
Among in-hospital outcomes, those with GI bleeding were more likely to experience death (12.1% vs. 3.2%; OR = 4.19; 95% CI, 3.21-5.49), cardiogenic shock (9.8% vs. 5.9%; OR = 1.72; 95% CI, 1.37-2.26), acute kidney injury (39.5% vs. 21.7%; OR = 2.35; 95% CI, 2.06-2.69), non-STEMI (11% vs. 3.4%; OR = 3.47; 95% CI, 2.66-4.54) and need for blood transfusion (31.3% vs. 11%; OR = 3.71; 95% CI, 3.14-4.34), Zahid and colleagues found.
In addition, those with GI bleeding had a higher median cost of stay ($68,779 vs. $46,995; P < .01) and a longer length of stay (11 days vs. 3 days; P < .01), according to the researchers.
“Patients who develop life-threatening GI bleeding need an urgent endoscopic intervention to stop the bleeding. Our study shows that those patients who got an endoscopic intervention had a lower rate of mortality compared with patients who were treated conservatively (9.6% vs. 12.8%),” Zahid told Healio. “The findings of our study are novel in that they quantify the risk and identify baseline characteristics that need to be a focus of intervention for preventing GI bleeding. “
Comorbidities conferring risk
The comorbidities associated with the highest odds of having GI bleeding were arteriovenous malformation (OR = 24.8; 95% CI, 17.13-35.92), peptic ulcer disease (OR = 8.74; 95% CI, 6.69-11.43) and colorectal cancer (OR = 7.89; 95% CI, 5.33-11.7), according to the researchers.
Other comorbidities associated with elevated risk for GI bleeding included chronic kidney disease (OR = 1.27; 95% CI, 1.14-1.41), congestive HF (OR = 1.18; 95% CI, 1.06-1.32), liver disease (OR = 1.83; 95% CI, 1.53-2.19), end-stage renal disease (OR = 2.08; 95% CI, 1.75-2.47), atrial fibrillation (OR = 1.63; 95% CI, 1.49-1.78) and lung cancer (OR = 2.8; 95% CI, 1.77-4.41), the researchers wrote.
“Our paper is the first to study GI bleeding after TAVR at a national level in the U.S. There are four main takeaway points,” Zahid told Healio. “No. 1, the study data can be utilized in discussions with patient when counseling on risk of GI bleeding, especially in patients having high-risk characteristics. No. 2, our findings support and provides guidance on the use of pre-TAVR screening endoscopy/colonoscopy for high-risk patients with high-risk characteristics (peptic ulcer disease, colorectal cancer, arteriovenous malformations and angiodysplasias). No. 3, patients with high-risk characteristics may be considered candidates for being discharged on proton pump inhibitors for at least 6 months. No. 4, at a national level for TAVR program planning purposes, we support that preventing GI bleeds by triaging high-risk patients will ultimately result in lowering hospitalization cost and lower resource utilization.”
For more information:
Salman Zahid, MD, can be reached at salman.zahid@rochesterregional.org.
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