Adapted with permission from S rensen et al.533 Table 13. Selected Risk Factors for Bleeding in Patients With ACS Advanced age (>75 y) Female sex HF or shock Diabetes mellitus Body size History of GI bleeding Presentation with STEMI or NSTEMI (vs UA) Severe renal dysfunction (CrCl <30 mL/min) Elevated white blood cell count Anemia Use of fibrinolytic therapy Invasive strategy Inappropriate dosing of antithrombotic medications Chronic oral anticoagulant therapy ACS indicates acute coronary syndrome; CrCl, creatinine clearance; GI, gastro intestinal; HF, heart failure; NSTEMI, non ST-elevation myocardial infarction; STEMI, ST-elevation myocardial infarction; and UA, unstable O Gara et al 2013 ACCF/AHA STEMI Guideline e397 major bleeding) and the individual secondary outcomes of death, MI, stroke, and overall mortality. However, rates of major bleeding were not lower with radial versus femoral access in patients with STEMI, though rates of major vascular complications were significantly reduced.561 Although arterial closure devices have been associated with decreased femoral access site bleeding, more rapid hemostasis, and shorter dura- tion of bed rest,251,562,563 their routine use cannot be advocated specifically to reduce vascular complications after PCI, given the lack of robust, directionally consistent data on their effi- cacy and safety compared with manual compression.564 566 Retroperitoneal bleeding should be suspected when the fol- lowing are seen: unheralded intraprocedural or postprocedural hypotension and bradycardia (or tachycardia), high vascular puncture site, and an otherwise unexplained decrease in hemo- globin. Prompt computed tomographic imaging of the abdo- men and pelvis may be helpful. Conservative management usually suffices, but early vascular interventional or surgical consultation should be obtained.219 9.8. Acute Kidney Injury The risk of renal failure with STEMI relates to a host of factors, including patient age, prehospital renal function, medications, contrast volume, and hemodynamic status. 