One in 5 patients with a major bleed did not survive to hospital discharge; these patients accounted for 10% of all hospital deaths and were older, more severely ill, and more likely to undergo invasive proce- dures. In ExTRACT-TIMI 25 (Enoxaparin and Thrombolysis Reperfusion for Acute Myocardial Infarction Treatment Thrombolysis In Myocardial Infarction 25), high 30-day mor- tality rates after major bleeding in patients with STEMI treated with fibrinolysis and either unfractionated or low-molecular- weight heparin were driven largely by the very poor progno- sis associated with ICH (65% mortality rate).537 The overall incidence of ICH in this study was 0.6%.332 The relationship between non-ICH bleeding and death in both ExTRACT-TIMI 25 and TRITON-TIMI 38 may have been confounded by patient attributes, severity of illness, and treatment protocols.537,550 To minimize the risk of bleeding complications, an assessment of patient, procedural, and pharmacological risk factors should be performed at time of presentation with STEMI and continu- ously thereafter. As an example, a longer time to PCI may be justifiable if the risk of hemorrhage with fibrinolysis is consid- ered prohibitive. Evidence suggests that although anemia is a risk factor for bleeding, the threshold for transfusion should be high.551 Absent ongoing ischemia, transfusion should be avoided unless the hemoglobin level is <8 mg/dL. The optimal hemo- globin level in the transfused patient is not known, but the number of units provided should be minimized.539,552 9.7.2.1. Treatment of ICH Older age, female sex, low body weight (<70 kg [female] and <80 kg [male]), prior stroke, and hypertension on presenta- tion (with a graded increase beginning at >160 to 170 mmHg systolic) are the major risk factors for ICH. Once ICH is rec- ognized, all antiplatelet and anticoagulant therapy should be stopped. Brain imaging with emergency neurological and neurosurgical consultation is required. 