LAUSR

The COVID-19 (SARS-CoV-2 virus) pandemic has unmasked several challenges for patients with ST-elevation myocardial infarction (STEMI) in the United States. Standard of care primary percutaneous coronary intervention (PPCI) has suffered system delays. There has been consideration of initial fibrinolytic therapy (FT)-based reperfusion strategies for patients with STEMI. Safety concerns of this strategy include the risk of intracranial hemorrhage (ICH) and other major bleeding. Contemporary trends and outcomes of bleeding with FT in the United States has not been reported. Additionally, risk factors associated with ICH with FT in contemporary times has not been investigated widely. We assessed contemporary US trends in use, and bleeding outcomes with FT among STEMI patients, and attempted to identify factors associated with ICH. The National Inpatient Sample (NIS) database was utilized for years 2009–2016 to identify STEMI patients who had FT using international classification of disease (ICD)-Ninth and Tenth revision codes. Pre-existing comorbidities were identified using algorithms from the healthcare cost and utilization project comorbidity software. Admissions with a primary diagnosis code for stroke or pulmonary embolism were excluded. Outcomes of interest—ICH and major bleeding (retroperitoneal bleeding, procedural bleed, need for transfusion, hemopericardium, gastrointestinal bleeding, hemarthrosis, hemoptysis, unspecified bleeds)—were ascertained with appropriate ICD codes (Table S1). We used the Cochran-Armitage test to evaluate the yearly trends in FT use, in-hospital ICH, and other major bleeding. We then developed a multivariable logistic regression model using backward selection to assess factors associated with ICH after FT. SAS version 9.4 and STATA12 (MP) were used for analysis. We identified a total of 259,419 STEMI admissions, of which a total of 2.13% (N = 6,306) patients received FT during the study period. Mean age was 64 (±14) years and 32% were female. Rate of ICH was 0.9% overall. We noted a slight nominal increase in utilization of FT-based reperfusion from 2009 (2.26%) to 2016 (2.81%) (p-trend <.001), without any significant increase in ICH or other major bleeding events by year, and overall decline (p-trend <.001) over the years assessed (Figure 1a). Age, and comorbidities including congestive heart failure, coagulopathy, diabetes mellitus, electrolyte disturbance, metastatic malignancy and pre-existing neurological disorders (including prior stroke) were associated with an increased risk of ICH–c-statistic of 0.75 (p < .001) (Figure 1B). The risk of ICH in patients without any risk factors (0.19%) was half that of the overall population (0.38%).