Incidence and subsequent prognostic impacts of gastrointestinal bleeding in patients with heart failure

Gastrointestinal function alterations occur in patients with chronic heart failure (CHF) as a result of low cardiac output and increased central venous pressure. Gastrointestinal bleeding (GIB) associated with antiplatelet therapy (APT) or anticoagulant therapy (ACT) is becoming a major problem in the management of coronary artery disease (CAD), as well as atrial fibrillation. However, the impacts of GIB on the subsequent prognosis of CHF patients have not yet been reported. CHF patients are often prescribed APT or ACT for several reasons, including presence of CAD, atrial fibrillation, stroke, peripheral artery disease, thrombosis and post-valve surgery. Furthermore, CHF patients tend to have a higher presence of any cancer. The purpose of the present study was to examine the incidence and sources of GIB, and the subsequent prognostic impacts of GIB in CHF patients. This was a prospective observational study of 2103 patients with CHF at Fukushima Medical University Hospital between 2010 and 2016. The enrolled CHF patients had regularly visited hospital for CHF treatment either monthly or bimonthly, and were followed up for GIB, cardiac events and all-cause death semiannually until 2018. GIB was defined as clinical bleeding from the gastrointestinal tract with a bleeding type 2 to 5 according to the Bleeding Academic Research Consortium (BARC) definition. The sources of GIB were detected by endoscopy, computed tomography and operatory finding, as much as possible. Cardiac events were defined as worsened heart failure and/or cardiac death. The incidence of GIB was 3.2% of the 2103 CHF patients, who were prescribed APT (49.0%), ACT (56.0%) and acid suppressive agents (71.2%), within a mean follow-up period of 1180 days. BARC classification of these patients were type 2 (n1⁄4 25, 36.8%), type 3 a (n1⁄4 19, 27.9%), type 3 b (n1⁄4 17, 25.0%) and type 5 b (n1⁄4 7, 10.3%). The sources of GIB were in the colon (cancer, adenoma, polyp, diverticulum, erosion, etc.; n1⁄4 30, 44.1%), stomach (ulcer, erosion, cancer, telangiectasia, polyp etc.; n1⁄4 18, 26.5%), duodenum (ulcer; n1⁄4 5, 7.4%), esophagus (esophagitis, varix; n1⁄4 3, 4.4%) and unknown (n1⁄4 l2, 17.6%). Thus, in the present study, the major source of GIB was the colon, rather than stomach or duodenum due to peptic ulcer. We focused on subsequent cardiac event rate and allcause mortality between the GIB and non-GIB groups. To investigate the subsequent prognostic impact of GIB, 2096 of the 2103 patients, after excluding deaths due to GIB events (n1⁄4 7), were examined. In the follow-up period, 594 cardiac events (including 318 worsening heart failure and 276 cardiac death) and 559 cases of all-cause mortality occurred. In the Kaplan–Meier analysis (Figure 1), the cardiac event rate and all-cause mortality were significantly higher in the GIB group than in the non-GIB group (logrank p< 0.001). In the univariable Cox proportional hazard analysis, the incidence of GIB was a subsequent predictor of cardiac event rate and all-cause mortality (cardiac event rate, hazard ratio 2.211, 95% confidence interval 1.455–3.358, p< 0.001; all-cause death, hazard ratio 2.850, 95% confidence interval 1.905–4.263, p< 0.001].