70DID YOU MEAN TO MAKE ME BLEED? TREATING FRAIL OLDER PEOPLE WITH NSTEMI CARRIES A HIGH RISK OF BLEEDING

Abstract

Introduction: NICE guidance recommends managing NSTEMI (Non-ST Elevation Myocardial Infarction) with dual antiplatelets and antithrombin therapy but asks clinicians to consider bleeding risk. Frail older people with co-morbidities such as anaemia, heart failure and chronic kidney disease are at higher risk of bleeding, and bleeding is associated with an increased risk of adverse outcomes and death. The risk of bleeding can be estimated using a scoring tool such as "CRUSADE." We wished to investigate how older people with NSTEMIs treated in the elderly medicine department of a large teaching hospital, i.e. deemed not suitable to be cared for by cardiologists, were treated, and whether they suffered adverse bleeding outcomes. Method(s): We conducted a retrospective case note analysis of 47 patients admitted to the elderly medicine department between April 2015 and April 2016. We recorded demographic details, co-morbidities, CRUSADE score, initial antithrombotic therapy, discharge antithrombotic therapy, changes in haemoglobin, whether blood transfusion was given, and whether patients were re-admitted in the next year with bleeding. Result(s): 41/47 patients (87%) had 2 or more co-morbidities. 35/47 patients (74%) were judged to have a high risk, or very high risk of bleeding as defined by the CRUSADE score. 30/47 patients (64%) were given at least 2 antithrombotic agents as initial treatment. 24/47 patients (51%) were discharged on dual antiplatelet therapy. 9/47 patients (19%) died during admission. 19/47 patients (40%) had a fall in haemoglobin during admission - 14 of these patients were classified as very high risk of bleeding using the CRUSADE score. The median fall in haemoglobin was 2 units. 12/47 patients (25%) had a blood transfusion during admission. 3/47 patients (6%) had a further admission with a bleeding related complication - this included one fatality. Conclusion(s): Patients admitted to the elderly medicine department with NSTEMI had a significant prevalence of multimorbidity and were commonly at high risk of bleeding. Use of dual or triple antithrombotic therapy is common, as is the incidence of bleeding. It is possible that we are over-treating patients with NSTEMI and multimorbidity. Use of a bleeding risk calculator such as CRUSADE may be helpful in identifying those patients at high risk of bleeding.