Management of patients with acute coronary syndromes in real-world practice in Italy: an outcome research study focused on the use of ANTithRombotic Agents: the MANTRA registry

Eur Heart J Acute Cardiovasc Care. 2013 Mar;2(1):27-34. doi: 10.1177/2048872612471213.


Background: Although outcomes of acute coronary syndromes (ACS) have greatly improved, bleeding is still an issue. Thus, this study aims to evaluate in-hospital management and outcomes of unselected patients with ACS focusing on antithrombotic therapies and bleeding.

Methods and results: From 22 April 2009 to 29 December 2010, 6394 consecutive Italian patients were prospectively enrolled and followed for 6 months. Most patients (55.3%) had non-ST-elevation (NSTE) ACS. Of the ST-elevation (STE) ACS patients, 79.8% received reperfusion (mainly mechanical). In-hospital and 6-month unadjusted total mortality rates were 4.2 and 7.8% for STE-ACS and 2.5 and 6.4% for NSTE-ACS, respectively. During hospitalization, TIMI major bleeding rate was 1.2% (1.4% STE-ACS and 1.1% NSTE-ACS, respectively) and TIMI minor bleeding was 3.1%. In-hospital and 6-month unadjusted total mortality rates were 3.1 and 6.7% for patients without bleeding, 1.5 and 8.6% for minor bleeding, and 19.0 and 26.6% for TIMI major bleeding, respectively (p<0.0001). Notably, TIMI major bleeding was one of the strongest predictors of the 6-month composite end point (death or reinfarction) (STE-ACS hazard ratio, HR, 2.86, 95% confidence interval, 95% CI, 1.57-5.23; NSTE-ACS HR, 2.71, 95% CI 1.52-4.80). Predictors of in-hospital TIMI major bleeding were weight (odds ratio, OR, 0.97, 95% CI 0.95-0.99), female gender (OR 1.80, 95% CI 1.09-2.96), history of peripheral vasculopathy (OR 2.95, 95% CI 1.83-4.78), switching anticoagulant therapy (OR 2.62, 95% CI 1.36-5.05), intra-aortic balloon pump implantation (OR 4.44, 95% CI 1.85-10.69), and creatinine ≥2 mg/dl on admission (OR 3.68, 95% CI 1.84-7.33).

Conclusions: Despite aggressive management, the rate of bleeding remains relatively low in an unselected ACS population. However, major bleeding adversely affects prognosis and physicians should tailor treatments to reduce it.

Keywords: Acute coronary syndromes; bleeding; outcome research.