***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background — Analyses from r and omized controlled trials suggest that bleeding in patients with acute myocardial infa rct ion is associated with poor outcomes . Because these data are not generalizable to all patients with acute myocardial infa rct ion , we sought to better underst and the scope of this problem in a “ real-world ” setting . Methods and Results — We examined the frequency of major bleeding  in 40 087 patients with acute myocardial infa rct ion enrolled in the Global Registry of Acute Coronary Events . Regression analyses were used to examine the association between patient and treatment characteristics , bleeding , and hospital and postdischarge outcomes . Major bleeding occurred in 2.8 % of patients . These patients were older , more severely ill , and more likely to undergo invasive procedures . Patients with bleeding were more likely to die during hospitalization ( hazard ratio , 1.9 ; 95 % confidence interval , 1.6 to 2.2 ) but not after discharge ( hazard ratio , 0.8 ; 95 % confidence interval , 0.6 to 1.0 ) than patients who did not bleed . Continuation of antithrombotic therapies after day 1 was lower in patients who experienced early bleeding . Moreover , in patients who bled , hospital mortality was increased in those who discontinued aspirin , thienopyridines , or low – molecular-weight heparins . Conclusions — Major bleeding occurred in 1 in 35 patients with acute myocardial infa rct ion ; these patients accounted for ≈10 % of all hospital deaths . Nevertheless , risk of hospital mortality associated with bleeding was much lower than reported in r and omized controlled trials . These data suggest that although bleeding may be causally related to adverse outcomes in some patients in the real-world setting , it is often merely a marker for patients at higher risk for adverse outcomes Aims Newer P2Y12 blockers ( prasugrel and ticagrelor ) demonstrated significant ischaemic benefit over clopidogrel after acute coronary syndrome ( ACS ) . However , both drugs are associated with an increase in bleeding complications . The objective of the present study was to evaluate the benefit of switching dual antiplatelet therapy ( DAPT ) from aspirin plus a newer P2Y12 blocker to aspirin plus clopidogrel 1 month after ACS . Methods and results We performed an open-label , monocentric , and r and omized trial . From March 2014 to April 2016 , patients admitted with ACS requiring coronary intervention , on aspirin and a newer P2Y12 blocker and without adverse event at 1 month , were assigned to switch to aspirin and clopidogrel ( switched DAPT ) or continuation of their drug regimen ( unchanged DAPT ) . The primary outcome was a composite of cardiovascular death , urgent revascularization , stroke and bleeding as defined by the Bleeding Academic Research Consortium ( BARC ) classification ≥2 at 1 year post ACS . Six hundred and forty six patients were r and omized and 645 analysed , corresponding to 322 patients in the switched DAPT and 323 in the unchanged DAPT group . The primary endpoint occurred in 43 ( 13.4 % ) patients in the switched DAPT group and in 85 ( 26.3 % ) patients in the unchanged DAPT ( HR 95%CI 0.48 ( 0.34 - 0.68 ) , P < 0.01 ) . No significant differences were reported on ischaemic endpoints , while BARC ≥ 2 bleeding occurred in 13 ( 4.0 % ) patients in the switched DAPT and in 48 ( 14.9 % ) in the unchanged DAPT group ( HR 95%CI 0.30 ( 0.18 - 0.50 ) , P < 0.01 ) . Conclusion A switched DAPT is superior to an unchanged DAPT strategy to prevent bleeding complications without increase in ischaemic events following ACS Background —Previous data on bleeding after percutaneous coronary intervention ( PCI )  have been obtained primarily from r and omized trials that focused on in-hospital bleeding . The incidence of late bleeding after PCI , its independent predictors , and its prognostic importance in clinical practice has not been fully addressed . Methods and Results —We evaluated 22 798 patients aged > 65 years who underwent PCI from December 1 , 2003 , to March 31 , 2007 , in Ontario , Canada . Cox proportional hazard models were used to determine factors associated with late bleeding , which was defined as hospitalization for bleeding after discharge from the index PCI , and to estimate risk of death or myocardial infa rct ion associated with late bleeding . We found that 2.5 % of patients were hospitalized for bleeding in the year after PCI , with 56 % of bleeding episodes due to gastrointestinal bleed . The most significant predictor of late bleeding was warfarin use after PCI ( hazard ratio [ HR ] , 3.12 ) . Other significant predictors included age ( HR , 1.41 per 10 years ) , male sex ( HR , 1.24 ) , cancer ( HR , 1.80 ) , previous bleeding ( HR , 2.42 ) , chronic kidney disease ( HR , 1.93 ) , and nonsteroidal antiinflammatory drug use ( HR , 1.73 ) . After adjusting for baseline covariates , hospitalization for a bleeding episode was associated with a significantly increased 1-year hazard of death or myocardial infa rct ion ( HR , 2.39 ; 95 % CI , 1.93 to 2.97 ) and death ( HR , 3.38 ; 95 % CI , 2.60 to 4.40 ) . Conclusions —Hospitalization for late bleeding after PCI is associated with substantially increased risk of death and myocardial infa rct ion . The use of triple therapy ( ie , aspirin , thienopyridine , and warfarin ) is associated with the highest risk of late bleeding Background —Bleeding in patients undergoing percutaneous coronary intervention ( PCI )  is associated with increased morbidity , mortality , length of hospitalization , and cost . We identified baseline clinical characteristics associated with bleeding complications after PCI and developed a simplified , clinical ly useful algorithm to predict patient risk . Methods and Results — Data were analyzed from 302 152 PCI procedures performed at 440 US centers participating in the National Cardiovascular Data Registry . As defined by the National Cardiovascular Data Registry , bleeding required transfusion , prolonged hospital stay , and /or a drop in hemoglobin > 3.0 g/dL from any location , including percutaneous entry site , retroperitoneal , gastrointestinal , genitourinary , and other/unknown location . Bleeding complications occurred in 2.4 % of patients . From the best-fitting model consisting of 15 clinical elements associated with post-PCI bleeding in a r and om 80 % training cohort , we developed a parsimonious risk algorithm . Predictors of bleeding included age , gender , previous heart failure , glomerular filtration rate , peripheral vascular disease , no previous PCI , New York Heart Association/Canadian Cardiovascular Society Functional Classification class IV heart failure , ST-elevation myocardial infa rct ion , non – ST-elevation myocardial infa rct ion , and cardiogenic shock . The parsimonious model was vali date d in the remaining 20 % of the population ( c-statistic , 0.72 ) and in clinical ly relevant subgroups of patients . This simplified model was used to derive a clinical risk algorithm , with larger numbers corresponding with greater risk . In 3 categories , bleeding rates were greater in patients with higher estimates ( ≤7 , 0.7 % ; 8 to 17 , 1.8 % ; ≥18 , 5.1 % ) . Conclusions —This report identifies baseline clinical factors associated with bleeding and proposes a clinical ly useful algorithm to estimate bleeding risk . This model is potentially actionable in altering therapeutic decision making and improving outcomes in patients undergoing PCI Objective To evaluate changes in residual platelet reactivity ( RPR ) over time , and bleeding and ischaemic events rate using 5 vs 10 mg maintenance dose ( MD ) regimens of prasugrel 1 month after acute coronary syndrome ( ACS ) . Background The optimal level of RPR with prasugrel may change over time after an ACS . Methods After 60 mg loading dose of prasugrel ( T0 ) followed by 10 mg/day for 1 month , patients were r and omised to receive prasugrel 10 mg/day ( n=95 , group A ) or 5 mg/day MD ( n=98 , group B ) up to 1 year . RPR was assessed at T0 , 37 ( T1 ) and 180 days ( T2 ) . The primary end point was Bleeding Academic Research Consortium ( BARC ) bleeding events ≥2 between 1 and 12 months , and the secondary composite end point was cardiac death , myocardial infa rct ion , stroke and definite/probable stent thrombosis . Results From T0 to T1 , RPR significantly increased in both groups A and B and the increase was higher for group B ( δ ADP 10 µmol : 13.8%±14.7 % vs 23.5%±19.2 % , p=0.001 ) . At T2 a lower rate of high RPR patients were found in group A ( 2.6 % vs13.3 % ; p=0.014 ) . The BARC type ≥2 bleeding occurred in 12.6 % of group A versus 4.1 % of group B ( OR 0.29 , 95 % CI 0.09 to 0.94 ) and secondary end point in 2.1 % vs 1.0 % ( p=0.542 ) , respectively , without stent thrombosis . Conclusions RPR increases shifting from 60 mg loading dose to 10 mg/day prasugrel MD with a further increase of RPR reducing prasugrel MD to 5 mg 1 month after ACS . Clinical value of these pharmacodynamic findings should be proved in larger clinical trials . Trial registration number NCT01790854 OBJECTIVES The purpose of this study was to determine the predictors of major bleeding and the impact of major bleeding on outcomes , including mortality , in acute coronary syndromes ( ACS ) . BACKGROUND Whether major bleeding independently predicts mortality in patients with ACS undergoing an early invasive strategy is undefined . METHODS Patients ( n = 13,819 ) with moderate- and high-risk ACS were r and omized to heparin ( unfractionated or enoxaparin ) plus glycoprotein IIb/IIIa inhibition ( GPI ) , bivalirudin plus GPI , or bivalirudin monotherapy ( plus provisional GPI ) . Logistic regression was used to determine predictors of 30-day major bleeding and mortality . RESULTS Major bleeding rates in patients treated with heparin plus GPI were higher versus bivalirudin monotherapy ( 5.7 % vs. 3.0 % , p < 0.001 ) and similar versus bivalirudin plus GPI ( 5.7 % vs. 5.3 % , p = 0.38 ) . Independent predictors of major bleeding were advanced age , female gender , diabetes , hypertension , renal insufficiency , anemia , no prior percutaneous coronary intervention , cardiac biomarker elevation , ST-segment deviation > /=1 mm , and treatment with heparin plus GPI versus bivalirudin monotherapy . Patients with major bleeding had higher 30-day rates of mortality ( 7.3 % vs. 1.2 % , p < 0.0001 ) , composite ischemia ( 23.1 % vs. 6.8 % , p < 0.0001 ) , and stent thrombosis ( 3.4 % vs. 0.6 % , p < 0.0001 ) versus those without major bleeding . Major bleeding was an independent predictor of 30-day mortality ( odds ratio 7.55 , 95 % confidence interval 4.68 to 12.18 , p < 0.0001 ) . CONCLUSIONS Major bleeding is a powerful independent predictor of 30-day mortality in patients with ACS managed invasively . Several factors independently predict major bleeding , including treatment with heparin plus GPI compared with bivalirudin monotherapy . Knowledge of these findings might be useful to reduce bleeding risk and improve outcomes in ACS AIMS We assessed prospect ively the association between occurrence of post-discharge non-CABG-related TIMI major and minor bleeding  and post-treatment platelet reactivity in patients with non-ST elevation acute coronary syndrome ( NSTE ACS ) . METHODS AND RESULTS Five hundred and ninety-seven consecutive patients admitted with NSTE ACS were prospect ively included . Between hospital discharge and one month follow-up , we observed 16 ( 2.7 % ) non-CABG-related TIMI haemorrhagic complications including five ( 0.84 % ) major and 11 ( 1.8 % ) minor bleeds . Patients with bleeding had significantly lower post-treatment values of ADP-induced aggregation ( 43+/-14 % versus . 56+/-19 % , p=0.002 ) and platelet reactivity index VASP ( 43+/-14 % versus 54+/-23 % ; p=0.04 ) and a trend for lower values of arachidonic acid-induced aggregation ( 2. 
    Output:
    
The majority of bleeds occurred in the initial 3 months after hospital discharge with bruising the most commonly reported event .
Conclusion Bleeding complications following ACS management are common and continue to occur in the long term after hospital discharge .
These bleeding complications may increase the risk of mortality and MACE , but greater evidence is needed to assess their long-term effects .