ACOSTA, Hillary Joy I.

September 14,
2020
3NUR1 – RLE 1 Mrs. Georgina H.
Manzano

 Title of the Article: Impact of Anemia on the Risk of Bleeding Following

Percutaneous Coronary Interventions in Patients ≥75 Years of Age
 Authors: David Marti, Damaris Carballeira, Maria Jose Morales, Ricardo
Concepcion, Hugo del Castillo, Alexander Marschall, Freddy Andres Delgado-Calva,
Carmen Dejuan-Bitria, Joaquin Perez-Guzman, Edurne Lopez-Soberon, Jorge
Palazuelos, and Salvador Alvarez-Anton
 APA format of Bibliography: Martí, D., Carballeira, D., Morales, M. J., Concepción,
R., del Castillo, H., Marschall, A., … Álvarez-Antón, S. (2020). Impact of Anemia on
the Risk of Bleeding Following Percutaneous Coronary Interventions in Patients ≥75
Years of Age. The American Journal of Cardiology.
doi:10.1016/j.amjcard.2020.01.010 
 Source of the Article: ScienceDirect
 Key terms used for the Search: Anemia, Elderly

Guide Questions (LEVEL 3 – 1st Term)

1. What is the significance of the research article you have chosen in your Related
Learning Experience?
The research article I chose is mainly about how anemia can affect bleeding in
the elderly. The sample was taken from a university hospital who were treated by urgent
or elective Percutaneous Coronary Interventions (PCI). It is a type of non-surgical
procedure wherein a catheter is used to place a metal mesh tubes called a stent to
widen the stenotic blood vessel in the heart. First, it will be inserted in the femoral or
radial artery towards the heart. Then, a dye will be injected so that the narrowed area
within the vessel will be identified. Once located, the narrowed area in the heart caused
by a plaque buildup will be put with a bare-metal or drug-eluting stent. Its purpose is to
open the blocked artery by temporarily inserting and inflating a tiny balloon. In the study,
among the 448 qualified patients with ages 75 years and older, 174 of them were
identified to have anemia. It is 39% of the sample and is relatively high. It was found
that anemia is a frequent finding in patients undergoing PCI and it could exacerbate
after the treatment. Therefore, it is important to identify bleeding risks like anemia
whenever a patient is undergoing either a noninvasive or invasive treatment. Healthcare
providers can use risk stratification to better target a patient’s needs and rule out
possible complications. Also, anemia is associated with significant increases in post-
procedural mortality, reinfarction, and bleeding. Therefore, anemia can be used as a
potent predictor of bleeding in such patients. In relation to my Related Learning
Experience, I could handle an elderly patient who is at risk for bleeding and has
undiscovered anemia. Therefore, it is important to review the patient’s chart to see
whether the patient’s lab results show that he or she has a low hemoglobin level.
 According to WHO, anemia is when the hemoglobin concentration is <12 g/dL in women
and <13 g/dL in men. With the baseline hemoglobin provided, I would be able to identify
if a patient is anemic or not.
2. What are the implications of the findings in your patient care?
In the research article, the researchers made use of several procedures such as
getting the hemoglobin level of the patient and using the CRUSADE and PRECISE-
DAPT scores to determine the predictive ability of bleeding. They obtained patient
information such as the HR, Systolic BP, Hematocrit, Sex, Creatinine Clearance, Signs
of CHF at presentation, history of DM, and history of vascular disease for CRUSADE;
while age, creatinine clearance, hemoglobin, white blood cell count, and previous
spontaneous bleeding for PRECISE-DAPT. Although the use of risk scores for the
selection of dual antiplatelet therapy (DAPT) is recommended, the results showed that
risk scores are not that accurate most especially to anemic patients. It is said that the
CRUSADE score depends largely on renal function, which we know greatly impacts
ischemic events, so its ability to discriminate ischemia or bleeding is also limited. On the
other hand, moderate grades of hemoglobin levels were strongly related to the
incidence of bleeding possibly due to a higher prevalence of subclinical bleeding, blood
dyscrasia, or chronic inflammation. For instance, patients with moderate-to-severe
anemia had higher nonstatistically significant frequencies of chronic kidney disease
(33.8% vs 22.0%), previous heart failure (24.6% vs 18.3%) or malignancy (10.8% vs
7.3%) versus mildly anemic patients. Therefore, baseline hemoglobin is superior to the
prediction of bleeding.

With the sample of patients aged 75 years and older, we can conclude that the
prevalence of anemia increases with age. The findings show that these elderly patients
are prone to an uncertain risk of bleeding, especially those patients with moderate-to-
severe anemia. Providing care for the anemic elderly patients is important.

3. What intervention/ innovation was used or implemented in the study reviewed?

The research article made use of anemia as a potent predictor of bleeding to
elderly patients and compared it with established bleeding risk scores namely
CRUSADE and PRECISE-DEPT. In the study, it was found that anemia is prevalent as
age increases. In patients aged 65 to 74, there is an increase of 7% to 8% while in
patients aged 85 and above, it can reach an increase of 20 to 25%. However, in the
population that is admitted for PCI, anemia is more common in relation to the
prevalence of vascular diseases, antithrombotic treatments, and chronic pathologies.
The findings show that anemia has a reported prevalence of 40% and 16% in 2 large
PCI cohorts with average ages of around 70 and 65 years while a prevalence of 39% in
patients aged 75 years and above. The result of the study is consistent with previous
estimates and those diagnosed with anemia, half of them were mild anemia and did not
associate a higher incidence of bleeding. They might probably be cases that correspond
to nutritional deficits. Furthermore, the highest incidence of bleeding was found in the
population of patients with moderate-to-severe anemia. The majority of the reported
 anemic patients were women. However, the impact of anemia severity on the incidence
of bleeding was similar in both genders.

4. Does the intervention support/contradict current nursing practice? Support your

answer using other relevant references (suggestion: use Nursing reference center,
current clinical practice guidelines, books and other references)

There were already published researches that analyzed the prognostic value of
anemia. The focus of this research article is on the older population wherein bleeding is
the main outcome. As in recent publications, the researchers excluded anticoagulated
patients as they are reported to have a high bleeding risk. Besides, the main interest is
stratification for clinical decision-making in nonanticoagulated patients who present an
uncertain risk of bleeding. Among the procedures used in the study, results showed that
baseline anemia is the most superior in assessing bleeding risk. It is a readily available,
easily interpretable, and a potent risk factor for major bleeding following PCI in the older
adults. In addition to that, testing for the hemoglobin level showed doubled positive
predictive value with respect to the other procedures although all 3 procedures showed
good negative predictive value. Hemoglobin <11 g/dl preferentially identifies
hemorrhagic versus ischemic risk, and the absence of anemia would identify a low-risk
group, despite age and high PRECISE-DAPT values, in which shortening the duration
of DAPT would not be justified.
The findings of the study were as follows: (1) anemia is a powerful independent
predictor of spontaneous bleeding, with 2.7-fold increases in the incidence of 1-year
non-access site-related major bleeding; (2) the risk of bleeding is notably high in
patients with Hb levels <11 g/dl; and (3) despite the limited predictive capacity of any of
them, Hb represents an attractive alternative to the more laborious scores, allowing a
simpler and faster patient classification. The patients who belong to the anemia group
had statistically higher all-cause mortality and a numerically higher incidence of
thrombotic events.
With all these findings and data gathered, we can conclude that the intervention used is
aligned with the current nursing practice. Laboratory procedures and blood sampling are
being used in hospitals. Anemic patients are also being treated with individualized care
just for them.

5. Would this practice change/improve process of patient care? Patient outcomes?

I could say that this intervention and findings would improve patient care. Starting
with assessing the risk factors for bleeding, we can focus on giving care to it. The
identification of the risks must be an imperative step before the selection of the optimal
treatment of the patient. Furthermore, early identification of anemia will help to establish
significant decisions regarding the intensity or duration of antiplatelet treatment. For the
case in the research article, we could give appropriate nursing care to anemic patients.
An example is to anticipate the need for a platelet transfusion once the platelet count
drops to a very low value or we can assist with the kind of treatment to be given to the
patient.
 For the patient outcomes, this research article would contribute to its
improvement by guiding the healthcare providers to identify the risk factors with the use
of what resource is available. As mentioned earlier, baseline anemia is a readily
available, easily interpretable, and a potent risk factor for major bleeding following PCI
in the older adults. In patients undergoing PCI, it is important to identify if the patient is
anemic so that it would not cause any further problems during the treatment regimen. In
addition, elderly patients must be given more medical attention and care because they
are more vulnerable. After a year, it was reported that some of the patients who
experience bleeding died within 30 days they bled.

6. Based on your knowledge and background of statistics:

 What is level of measurement of the outcome variable?

The level of measurement used is interval/ratio because the data gathered from the
sample needs to be measured. The most common summary measures used are the
mean, median, and mode. In the research article, the mean and standard deviation
were used to compare the bleeding risk scores between anemic and non anemic
patients. The researchers also compared the number of patients who experience major
bleeding (%) between the two groups of anemic and nonanemic patients.

 What is the aim of the study? (To compare or test for difference, Determine
relationship between variables?)
The study aims to determine the independent contribution of anemia to the risk of
bleeding in 448 patients aged 75 or more years and who have just undergone
percutaneous coronary interventions. Moreover, the study aims to assess the predictive
capacity of anemia compared with establish bleeding risk scores.

 What are the variables of the study? Independent, dependent and extraneous
variables?

Dependent variable – risk for bleeding

Independent variable – anemia, CRUSADE score, PRECISE-DEPT score
Extraneous variables – age, malignancy, creatinine

 What statistical treatment was used?

There were several tests used by the researchers to gather data that would contribute
to the whole study.

a. Independent sample t test – for continuous variables

b. Pearson’s chi-square test – for categorical variables
c. Kaplan-Meier method – used to calculate one-year survival curves
d. Log-rank statistic – to identify differences between groups of patients (anemic
and nonanemic)
 e. Cox proportional hazards survival model – assessed the relation between
baseline variables and bleeding
f. Backward stepwise Cox regression analysis – was used to assess the
following variables seen to be predictors of bleeding on univariate analysis (p
<0.05) as well as other known factors for bleeding.
g. Area under the curve (AUCs) – was used to calculate the receiver operating
characteristic curves and the corresponding area under it; to determine the
predictive ability of bleeding of Hb levels, CRUSADE, and PRECISE-DAPT
scores

 What are the assumptions before using the identified statistical test?

H0 – Anemia is not a potent predictor of bleeding.

H1 – Anemia is a potent predictor of bleeding.

 Is it appropriate? Justify your answer. (Support justification using statistical

references or use the following table)

The statistical test that greatly contributes to the findings of the study is the
regression analysis. The test described the relationship of a hemoglobin level of <11
g/dl and a hemoglobin level of ≥11 g/dl to the percentage of elderly patients who
experience major bleeding. Yes, it is appropriate since it is a type of test used for
interval/ratio data. There is a sample of 448 elderly patients. After they underwent PCI,
they were tested if they are anemic or not. After a year, they were assessed whether
there is a higher frequency of bleeding in patients with anemia or in those who are not
anemic.

7. Identify a nursing theory related to the article findings and discuss/describe how the
findings support/contradicts your identified nursing theory.

The nursing theory I can apply to my research article is Betty Neuman’s Health
Care Systems Model. It is based on the client’s relationship to stress, how he or she
responds to it, and reconstitution factors that are progressive in nature. In this theory,
the client is seen as an open system consisting of a basic structure or central core of
energy resources (physiologic, psychologic, sociocultural, developmental, and spiritual)
that is surrounded by two rings called lines of resistance. They symbolize the internal
factors that help the client defend against a stressor. Next, outside the lines of
resistance are two lines of defense. The inner line, which is a solid line represents the
person’s state of equilibrium or the state of adaptation developed and maintained over
time and considered normal for that person. The other line, which is a broken line, is
dynamic and can be rapidly altered over a short period of time. In relation to the
research article, an elderly patient is seen as an open system. The kind of stressor that
occurs to the patient is an intrapersonal stressor, those that occur within the individual.
So, for the case of the patients in the research article, bleeding is the intrapersonal
stressor. They were not able to adapt to their stressor because they have an underlying
condition (anemia) that affected how they respond to it. In Neuman’s systems model,
the role of the nurse is focused on retaining or maintaining system stability. Tertiary
prevention can be carried out to the patients because this level of prevention focuses on
readaptation and stability and helps return to wellness following treatment.