CRUSADE Score Research Articles

Prolonged dual antiplatelet therapy in an extended Phase 3 Cardiac Rehabilitation Program following myocardial infarction

Abstract Background Prolonged dual antiplatelet therapy (P-DAPT) is recommended in selected patients beyond 12 months after myocardial infarction (MI). Several risk scores have been developed to estimate the ischemic and bleeding risk and individualize the decision-making process. Purpose We aim to analyse the factors, including ischemic and bleeding scores, associated with P-DAPT prescription in MI patients submitted to a Cardiac Rehabilitation Program (CRP). Methods Patients with ST-segment elevation MI (STEMI) or occlusion MI (OMI) who were submitted to our CRP underwent Phase 2 CRP and were prospectively included. Patients were followed in an extended Phase 3 CRP, and a follow-up visit was scheduled 12 months after hospital discharge. Baseline and follow-up clinical characteristics and treatment after the 12-months visit were registered, specifically P-DAPT. Ischemic (DAPT score) and bleeding (PRECISE-DAPT and CRUSADE scores) risk scores were retrospectively computed. Predictors of P-DAPT were studied by univariate analysis and multivariable binary logistic regression. The model was tested by area under the curve (AUC) analysis in receiver operating characteristic curves. A p<0.05 was considered statistically significant. Results The cohort comprised 78 patients (mean age 61±11 years, 84.6% male). Anterior and inferior STEMI were the most common presentations (43.6% and 47.4%, respectively). The most prevalent cardiovascular risks factors were hypercholesterolemia (85.9%), hypertension (53.8%), smoking habit (46.2%) and diabetes mellitus (23.1%). P-DAPT was prescribed in 39 (50%) patients beyond 12 months after MI, primarily combining aspirin 100mg o.d. and ticagrelor 60mg b.i.d. (n=33, 84.6%). On multivariate analysis, variables associated with P-DAPT prescription were hypertension (HR 4.92 [1.37-17.68], p=0.02), diabetes mellitus (HR 5.13 [1.09-24.09], p=0.04), multivessel disease (HR 5.54 [1.55-19.79], p=0.008), and stent diameter <3mm (HR 5.46 [1.25-23.78], p=0.02). The predictive power of the model was excellent (AUC 0.88 [0.8-0.96], p<0.001). Ischemic (DAPT score) and bleeding (PRECISE-DAPT and CRUSADE) risk scores were not associated with P-DAPT neither in continuous form nor by using their standard cutoffs (≥2, <25 and >40 points, respectively). Conclusions In a real-life cohort of MI patients undergoing extended Phase 3 Cardiac Rehabilitation, P-DAPT was prescribed in half of the population. Clinical (hypertension and diabetes mellitus) and angiographic (multivessel disease and stent diameter <3mm) variables straightforwardly predict the likelihood of receiving P-DAPT, unlike ischemic and bleeding risk scores. The clinical consequences of this management should be further explored.Prolonged DAPT in Cardiac Rehabilitation

Short- and long-term performance of risk calculation tools for mortality in patients with acute coronary syndrome.

The mortality rate of acute coronary syndrome (ACS) remains high. Therefore, patients with ACS should undergo early risk stratification, for which various risk calculation tools are available. However, it remains uncertain whether the predictive performance varies over time between risk calculation tools for different target periods. This study aimed to compare the predictive performance of risk calculation tools in estimating short- and long-term mortality risks in patients with ACS, while considering different observation periods using time-dependent receiver operating characteristic (ROC) analysis. This study included 404 consecutive patients with ACS who underwent coronary angiography at our hospital from March 2017 to January 2021. The ACTION and GRACE scores for short-term risk stratification purposes and CRUSADE scores for long-term risk stratification purposes were calculated for all participants. The participants were followed up for 36 months to assess mortality. Using time-dependent ROC analysis, we evaluated the area under the curve (AUC) of the ACTION, CRUSADE, and GRACE scores at 1, 6, 12, 24, and 36 months. Sixty-six patients died during the observation periods. The AUCs at 1, 6, 12, 24, and 36 months of the ACTION score were 0.942, 0.925, 0.889, 0.856, and 0.832; those of the CRUSADE score were 0.881, 0.883, 0.862, 0.876, and 0.862; and those of the GRACE score 0.949, 0.928, 0.888, 0.875, and 0.860, respectively. The ACTION and GRACE scores were excellent risk stratification tools for mortality in the short term. The prognostic performance of each risk score was almost similar in the long term, but the CRUSADE score might be a superior risk stratification tool in the longer term than 3 years.

Ischaemic and haemorrhagic risk distribution in real-life patients with acute coronary syndromes

Background Effective treatment of non-ST-segment elevation acute coronary syndromes (NSTEACS) requires careful assessment of both ischaemic and bleeding risks. We aimed to analyse risk distribution and evaluate antiplatelet prescription behaviours in real-life settings. Methods Data from 1100 NSTEACS patients in Buenos Aires, Argentina, from the Buenos Aires I Registry, with a 15-month follow-up, were analysed. In-hospital and 6-month GRACE scores, CRUSADE, and Precise DAPT scores were calculated. Results The mean age was 65.4 ± 11.5 years with a majority being male (77.2%). In-hospital mortality was 2.7%, primarily due to cardiovascular causes (1.8%). Bleeding events occurred in 20.9% of patients, with 4.9% classified as ≥ BARC 3. Predominance of low bleeding (71.3%) and ischaemic (55.8%) risks on admission was observed. At 6 months, the low-risk Precise category (70.9%) and GRACE (44.1%) categories prevailed. Linear correlation analysis showed a moderately positive correlation (r = 0.61, p < .05) between ischaemic–haemorrhagic risks. Regarding the prescription of antiplatelet agents, in the low ischaemic–haemorrhagic risk group, there was a predominance of aspirin + clopidogrel (41.2%) over other high-potency antiplatelet regimens (aspirin + ticagrelor or prasugrel). In the low ischaemic and high haemorrhagic risk group, aspirin and clopidogrel were also predominant (58%). Conclusions Our analysis underscores the significant relationship between ischaemic and haemorrhagic risks during NSTEACS hospitalisation. Despite the majority of patients falling into the low-intermediate risk category, the prescription of P2Y12 inhibitors in real-life settings does not consistently align with these risks.

Abstract 14280: Real-World Study of Fondaparinux in Chinese Non-ST-Segment Elevation Acute Coronary Syndrome Patients: REFOCAS

Introduction: In NSTE-ACS patients, fondaparinux appears to have superior benefits than LWMH, however its application in patients with different risk stratification is still not obvious. Hypothesis: The use of fondaparinux or LMWH has an impact on prognosis in NSTE-ACS patients with different ischemic and bleeding risks. Methods: A multicenter, prospective, open-label, real-world study was conducted in 8066 adult patients with non-emergency PCI at 89 hospitals from July 2019 to July 2021. Patients received fondaparinux (2.5 mg/d) or LMWH (1 mg/kg, twice/day) , they were followed-up within 6-month. The GRACE and CRUSADE scores were used to stratify the included patients. The primary outcome was the incidence of NACCE (all-cause death, reinfarction, nonfatal stroke, or BARC≥type 2 bleeding) at 30 days, and secondary endpoints included BARC≥type 2 bleeding or MACE during hospitalization, 30 days, and six months. Results: In total, 5430 patients received fondaparinux treatment and 2636 received LMWH treatment, with 4976 and 2477 completed the trial respectively. The primary outcome occurred in 136 patients (2.7%) receiving fondaparinux and in 110 patients (4.4%) in LMWH [HR=0.608(0.471,0.785), p&lt;0.001]. The rate of BARC≥2 bleeding at 30-day was significantly lower in the fondaparinux group compared with the LMWH group[68(1.4%) vs. 66(2.6%), HR=0.509(0.361,0.716), P&lt;0.001]. Reduction in rate of NACCE and BARC ≥ type 2 bleeding were still observed during hospitalization and at six-month follow-up in fondaparinux group. In low bleeding risk individuals (CRUSADE score≤40), fondaparinux reduced the rate of BARC≥2 bleeding at 30-day by 0.9% compared with LMWH, which decreased by 3.1% in high bleeding risk individuals(CRUSADE score&gt;40). Among patients with low ischemic risk (GRACE score≤140 ), fondaparinux significantly reduced the incidence of NACCE, MACE, and BARC ≥ 2 bleeding at each follow-up visits. Conclusions: In Chinese patients with NSTE-ACS, fondaparinux reduced the incidence of the composite endpoint event of bleeding and ischemia of 30 days compared with LMWH. Meanwhile, fondaparinux exhibited better safety in patients with high bleeding risk, and in the low ischemic risk group, the overall efficacy and safety were also better than LMWH.

Comparison of the prognostic value of four different critical illness scores in patients with sepsis-induced coagulopathy.

In patients with sepsis-induced coagulopathy (SIC), the Chinese DIC scoring system (CDSS) of the Chinese Society of Thrombosis and Hemostasis score, the Japanese Association for Acute Medicine (JAAM) score, the International Society of Thrombosis and Hemostasis (ISTH), and the Can Rapid risk stratification of Unstable angina patients Suppress Adverse outcomes with Early implementation of the ACC/AHA Guidelines (CRUSADE) score were compared for their predictive significance (SIC). From August 2021 through August 2022, 92 SIC patients hospitalized in our hospital's Department of Critical Care Medicine served as study participants. Groups of patients were created with a bad prognosis (n = 35) and a favorable prognosis (n = 57) 14 days following admission. Electronic medical records were used to compile patient information such as demographics (gender, age, and body mass index), medical history (hypertension, diabetes, chronic obstructive pulmonary disease, and chronic kidney disease), treatment (mechanical ventilation, APACHE II score at admission), and outcomes (results). All patients' JAAM, CDSS, ISTH, and CRUSADE scores were recorded. The APACHE II scores of the group with a poor prognosis were noticeably (p < 0.05) higher upon admission than those of the group with a favorable prognosis. The poor prognosis group had higher JAAM, ISTH, CDSS, and CRUSADE scores than the good prognosis group (all p < 0.05). Partial coagulation indicators in fibrinogen, D-dimer, activated partial thromboplastin time, and prothrombin time were positively linked with JAAM, ISTH, CDSS, and CRUSADE (all p < 0.05). At admission, the JAAM, ISTH, CDSS, CRUSADE, and APACHE II scores were independently linked with SIC patients' prognosis (all p < 0.05) in a multivariate logistic regression analysis. According to receiver operating characteristic analysis, the area under the curve for predicting the prognosis of SIC patients using the JAAM, ISTH, CDSS, and CRUSADE4 scores was 0.896, 0.870, 0.852, and 0.737, respectively, with 95% CI being 0.840-0.952, 0.805-0.936, 0.783-0.922 and 0.629-0.845, respectively (all p < 0.05). The prognosis of SIC patients may be predicted in part by their JAAM, ISTH, CDSS, and CRUSADE4 scores, with the CDSS score being the most accurate. This research provides important recommendations for improving the care of patients with SIC.

Clinical characteristics and outcomes of patients with intracerebral hemorrhage after acute myocardial infarction

Data regarding patients with intracranial hemorrhage (ICH) following acute myocardial infarction (AMI) is scarce. This study aims to investigate the incidence, clinical characteristics, prevention, treatment, and prognosis of ICH in patients with AMI.Among 5257 patients with AMI, 14 cases (0.27%) experienced ICH following AMI, including 11 males and three females. In-hospital mortality occurred in eight patients (57.1%), all of whom experienced sudden loss of consciousness. Six patients (42.6%) were classified as high or very high risk according to CRUSADE score, and seven patients (50.0%) were classified as high risk according to Academic Research Consortium for High Bleeding Risk (ARC-HBR). The CRUSADE and ARC-HBR scores can complement each other in risk assessment. All in-hospital deaths occurred within four days of ICH onset; The volume of ICH in patients who died in the hospital was significantly higher than in those who survived and were discharged, with 30 ml possibly serving as a threshold.The incidence of ICH following myocardial infarction is low; however, the mortality rate is extremely high, presenting considerable challenges for clinical treatment. Prevention, early detection, and prompt symptomatic management are essential for improving patient outcomes.

The prognostic value of ORBIT risk score in predicting major bleeding in patients with acute coronary syndrome

BackgroundThe most significant adverse effect of antithrombotic medication in acute coronary syndrome (ACS) is major bleeding, which is related to increased mortality. Studies on ORBIT risk score in predicting major bleeding in ACS patients are limited. ObjectiveThis research aimed to examine whether the ORBIT score calculated at the bedside can identify major bleeding risk in patients with ACS. MethodsThis research was retrospective, observational, and conducted at a single center. Analyses of receiver operating characteristics (ROC) were utilized to define the diagnostic value of CRUSADE and ORBIT scores. The predictive performances of the two scores were compared using DeLong's method. Discrimination and reclassification performances were evaluated by the integrated discrimination improvement (IDI), and net reclassification improvement (NRI). ResultsThe study included 771 patients with ACS. The mean age was 68.7 ± 8.6 years, with 35.3 % females. 31 patients had major bleeding. Twenty-three of these patients were BARC 3 A, five were BARC 3 B, and three were BARC 3 C. Bleeding history [OR (95 % CI), 2.46 (1.02–5.94), p = 0.021], hemoglobin levels [OR (95 % CI), 0.54 (0.45–0.63), p < 0.001], and age > 74 years [OR (95 % CI), 1.03 (1.01–1.06), p = 0.039] were independent predictors of major bleeding. The ORBIT score was an independent predictor of major bleeding in the multivariate analysis: continuous variables [OR (95 % CI), 2.53 (2.61–3.95), p < 0.001] and risk categories [OR (95 % CI), 3.06 (1.69–5.52), p < 0.001]. Comparison of c-indexes for major bleeding events revealed a non-significant difference for the discriminative ability of the two tested scores (p = 0.07) with a continuous NRI of 6.6 % (p = 0.026) and an IDI of 4.2 % (p < 0.001). ConclusionIn ACS patients, the ORBIT score independently predicted major bleeding.

Women take longuer to seek help when suffering a STEMI

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Historically, the prognosis of those women suffering a STelevation myocardial infarction (STEMI), has been worse compared to men. Some causal factors are presentation at later ages, atypical symptoms, lower perception of risk and less sensitivity of the health care providers. Purpose Our hypothesis is that there are still differences in the presentation of STEMI based on gender, which could be identified to guide new public campaigns in this perspective. Therefore our primary outcome is to find gender differences in symptoms and time delays in a cohort of STEMI patients, and secondary outcomes are differences in mortality and bleeding. Methods We conducted a retrospective analysis carried out in the Acute Cardiac Care Unit (ACCU) of a tertiary care hospital, where 50% of the medical staff are women. Patients hospitalized for STEMI for one year were included and a detailed caracterization of symptoms, time delays, and adverse events was recorded. Finally, the patients were classified according to gender, and differences in primary and secondary outcomes between both groups were analyzed. Results Between May/2020 and May/2021, 1056 patients were admitted to the ACCU, 33% were women. A total of 115 STEMI patients were included for the analysis, 21% were women. Basal characteristics of both groups were equivalent, except for a non significand trens towards less prevalence of peripheral arterial disease in women (0% vs. 11%; OR 0.890, IC 95% 0.828-0.957; p=0.089). Opressive chest pain was the most frequent symptom, but it was less frequent in women (75% vs. 91.4%, OR 0.284, IC 95% 0.085-0.948; p=0.033), whereas they presented more frequently with stabbing pain (13% vs. 2.4%, OR 6, IC 95% 1.073-38.35; p=0.035), and their pain was more frequently radiated towards the neck (28.6% vs. 4.9%, OR 7.7, IC 95% 1.1936-30.631; p=0.001), and associated to nausea/vomiting (45% vs. 1.3%, OR 5.809, IC 95% 1.930-17.486; p=0.001). There was a non-significant trend towards a longer time delay between pain onset and seek for help in women (185min IQR 747 vs. 60min IQR 454, p=0.098), being the other system time delays equivalent between both gender groups. Women had an increased bleeding risk, with a higher CRUSADE score (47.48 ± 22.92 vs. 28.60 ± 16.72, p=0.001) and higher incidence of bleeding events (12.55% vs. 0%, OR 11.68, IC 95% 9.82-13.29, p=0.001). There were no differences in the treatments administered or in mortality (12.5% vs. 14.3%, p=0.822). Conclusions Women suffering a STEMI more often reported stabbing chest pain, radiating to the neck, and associated to nausea/vomiting compared with men, and took longer to seek for help. These findings could help in the design of future campaigns to minimize time delays, targeting these different symptoms in female population.

Antiplatelet de-escalation switch in patients with acute coronary syndrome and percutaneous revascularisation in real life

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The current indication for the use of potent antiplatelet agents as the first choice after drug-eluting stent implantation in acute coronary syndrome (ACS) is sometimes difficult to achieve due to clinical problems in patients. The switch between higher and lower potency antiplatelet drugs (de-escalation) is particularly relevant and it is usually performed when there are contraindications or adverse effects related to the use of more potent P2Y12 inhibitors (iP2Y12). Purpose Our aim is to analyse the incidence and possible causes of in-hospital de-escalation switching in patients with ACS, as well as to compare the characteristics of these patients with those who continue with the higher potency antiplatelet drug initially indicated. Methods Observational, retrospective, single-centre study of a cohort of 3139 patients admitted to a Coronary Care Unit with ACS, treated with Ticagrelor or Prasugrel as a second antiplatelet agent at admission. Patients were classified according to whether or not they switched to Clopidogrel during their hospitalisation, comparing the characteristics between each group and the clinical events that potentially have caused that switch. Results From 3139 admitted patients, 188 (5.99%) were switched from Ticagrelor or Prasugrel to Clopidogrel. The majority of these occurred among patients receiving Ticagrelor (4.21 vs. 1.78%). Patients with de-escalation switch (mean age 64±11 years, 69% male) were similar to the non-switch group, with no statistical differences in baseline characteristics including the CRUSADE score (25 vs 27), except for the presence of a lower GRACE score (153 vs 146, P=0.02). The diagnosis of ST-elevation ACS as an ischaemic event was more prevalent in the "switch group". Regarding possible causes of de-escalation, a higher frequency of bleeding (9.3 vs 20.7%, P&amp;lt;0.01), new-onset atrial fibrillation (4.14 vs 20.21%, P&amp;lt;0.01) and indication for anticoagulation at discharge (6.64 vs 31.91 %, P&amp;lt;0.01) were observed in the "switch group" compared to the other one. Conclusions Although not very frequent, in-hospital de-escalation switch between iP2Y12 antiplatelet agents is sometimes required because of medical conditions, such as the presence of haemorrhages or the need for anticoagulation due to atrial fibrillation or other reasons; although, other times it happens due to a medical decision, without an objective event. In addition, in our sample, patients who underwent anti-platelet de-escalation switch had a lower ischaemic risk.

Accuracy in precise DAPT score compared with CRUSADE score in Thai population

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Rajavithi hospital Introduction Myocardial infarction is one of the most common cardiovascular disease in the world including Thai population. The current treatment strategy is percutaneous coronary intervention (PCI) with drug eluting stent (DES) which need to receive aspirin and P2Y12 inhibitor called Dual antiplatelets (DAPT) The previous studies showed unwanted bleeding in patients who received DAPT. Many scores are developed and valid to use as indicator of bleeding risk. However, the study of accuracy, performance and validity of Precise DAPT and CRUSADE score in Thailand are still limited. Method and Materials This is retrospective study of Thai patients aged 20 – 85 years old diagnose with acute coronary syndrome (ACS) and chronic coronary syndrome (CCS) who underwent PCI with DES and took DAPT for 6 months in CCS and 1 year in ACS at Rajavithi hospital from 2017 to 2019. Exclusion criteria are patients who take anticoagulant, previous major bleeding, currently received DAPT. We calculated the Precise DAPT score and CRUSADE score of the enrolled patients and follow up the bleeding events for 1 year. Objectives The primary outcome is the accuracy of the Precise DAPT score and the secondary outcome is to compare the performance of the Precise DAPT and Crusade score. Results Total of 90 patients were enrolled in this study with mean age of 63 ± 11.8 years old. Mainly are males (73.3%). The diagnosis of patients with STEMI 31.1%, NSTEMI/UA 38.8% and CCS 30.0%. The bleeding events defined by TIMI major and minor bleeding were 6 patients comprised of 1 TIMI major and 5 TIMI minor events. The bleeding events in Precise DAPT score &amp;lt; 25 were 3 of 47 patients (6.4%) compared with Precise DAPT score ³25 were 3 of 43 patients (7.0%) The events of bleeding in CRUSADE score &amp;lt;31 were 2 of 39 patients (5.1%), CRUSADE score 31-40 were 2 of the 17 patients (11.8%) and CRUSADE score &amp;gt; 40 were 2 of 34 patients (5.9%). The accuracy of Precise DAPT and CRUSADE score to predict TIMI major bleeding by ROC curve were excellence with AUC of Precise DAPT score = 0.955 (95%CI 0.912-0.998) and AUC of CRUSADE score =0.966 (95%CI 0.927-1.000). However, the Accuracy of Precise DAPT score and CRUSADE score to predict TIMI major and minor bleeding by ROC curve were poor with AUC = 0.529 (95%CI 0.250-0.799) and AUC = 0.531 (95%CI 0.254-0.807) respectively. The sensitivity and specificity of the cut-off ³ 25 point in Precise DAPT is 50.0 % and 57.1%%, respectively. While the sensitivity and specificity of the cut-off &amp;gt; 40 in CRUSADE score is 33.0% and 63.1% respectively. Conclusions This study showed that Precise DAPT score with cut-off ³ 25 and CRUSADE score with cut-off &amp;gt;40 have excellent accuracy to predict TIMI major bleeding but poor accuracy on TIMI minor bleeding in patients who take DAPT after PCI with DES.

Performance of the ATRIA Bleeding Score in Predicting the Risk of In-Hospital Bleeding in Patients with ST-Elevation or Non-ST-Elevation Myocardial Infarction.

A clear assessment of the bleeding risk score in patients presenting with myocardial infarction (MI) is crucial because of its impact on prognosis. The Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA score is a validated risk score to predict bleeding risk in atrial fibrillation (AF), but its predictive value in predicting bleeding after percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) or non-STEMI (NSTEMI) patients receiving antithrombotic therapy is unknown. Our aim was to investigate the predictive performance of the ATRIA bleeding score in STEMI and NSTEMI patients in comparison to the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association Guidelines) and ACUITY-HORIZONS (Acute Catheterization and Urgent Intervention Triage strategY-Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) bleeding scores. A total of 830 consecutive STEMI and NSTEMI patients who underwent PCI were evaluated retrospectively. The ATRIA, CRUSADE, and ACUITY-HORIZONS risk scores of the patients were calculated. Discrimination of the three risk models was evaluated using C-statistics. Major bleeding occurred in 52 (6.3%) of 830 patients during hospitalization. Bleeding scores were significantly higher in the bleeding patients than in non-bleeding patients (all P<0.001). The discriminatory ability of the ATRIA, CRUSADE, and ACUITY-HORIZONS bleeding scores for bleeding events was similar (C-statistics 0.810, 0.832, and 0.909, respectively). The good predictive value of all three scores for predicting the risk of bleeding was observed in NSTEMI and STEMI patients as well (C-statistics: 0.820, 0.793, and 0.921 and 0.809, 0.854, and 0.905, respectively). This study demonstrated that the ATRIA bleeding score is a useful risk score for predicting major in-hospital bleeding in MI patients. This good predictive value was also present in STEMI and NSTEMI patient subgroups.

Machine learning for prediction of bleeding in acute myocardial infarction patients after percutaneous coronary intervention.

Prediction of bleeding is critical for acute myocardial infarction (AMI) patients after percutaneous coronary intervention (PCI). Machine learning methods can automatically select the combination of the important features and learn their underlying relationship with the outcome. We aimed to evaluate the predictive value of machine learning methods to predict in-hospital bleeding for AMI patients. We used data from the multicenter China Acute Myocardial Infarction (CAMI) registry. The cohort was randomly partitioned into derivation set (50%) and validation set (50%). We applied a state-of-art machine learning algorithm, eXtreme Gradient Boosting (XGBoost), to automatically select features from 98 candidate variables and developed a risk prediction model to predict in-hospital bleeding (Bleeding Academic Research Consortium [BARC] 3 or 5 definition). A total of 16,736 AMI patients who underwent PCI were finally enrolled. 45 features were automatically selected and were used to construct the prediction model. The developed XGBoost model showed ideal prediction results. The area under the receiver-operating characteristic curve (AUROC) on the derivation data set was 0.941 (95% CI = 0.909-0.973, p < 0.001); the AUROC on the validation set was 0.837 (95% CI = 0.772-0.903, p < 0.001), which was better than the CRUSADE score (AUROC: 0.741; 95% CI = 0.654-0.828, p < 0.001) and ACUITY-HORIZONS score (AUROC: 0.731; 95% CI = 0.641-0.820, p < 0.001). We also developed an online calculator with 12 most important variables (http://101.89.95.81:8260/), and AUROC still reached 0.809 on the validation set. For the first time, we developed the CAMI bleeding model using machine learning methods for AMI patients after PCI. NCT01874691. Registered 11 Jun 2013.

Bleeding risk in patients hospitalized for non-ST-segment elevation acute coronary syndromes in Switzerland: performance of the CRUSADE score

Abstract Background Evaluation of bleeding risk is critical to the management of patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS). The CRUSADE score is the most established tool to estimate major bleeding events following the index NSTE-ACS. Purpose We aimed to assess the performance of the CRUSADE score and the predictive utility of the individual score variables in contemporary European populations. Methods The CRUSADE score was studied in prospectively recruited Swiss patients with NSTE-ACS included in the multicentre SPUM-ACS study (n=4'787) and main findings were validated in the nation-wide AMIS Plus registry (n=46'939). Major bleeding during hospitalization was defined as Bleeding Academic Research Consortium (BARC) class IIIB, IIIC, IV, or V. Discrimination was evaluated by the area under the receiver operating characteristic curve (AUC). Multivariable-adjusted risk ratios (adj RR) were estimated for each of the 8 score variables. Hematocrit estimates were based on hemoglobin concentrations in AMIS Plus. Analyses were performed on complete and imputed data (multiple imputation using chained equations). Results CRUSADE showed poor discriminatory performance (SPUM-ACS: AUC, 0.65; 95% CI 0.57 to 0.72) and low balanced accuracy (SPUM-ACS: 0.50). Risk predicted by CRUSADE exceeded the observed risk across all predefined risk categories (very low, low, moderate, high, and very high). Decision curve analyses suggested little to no net benefit from using the score. Adjusting for other score variables, signs of heart failure (adj RR, 3.83; 95% CI, 1.93 to 7.37), low hematocrit (adj RR, 2.16; 95% CI, 0.55 to 7.70; &amp;lt;31% vs. &amp;gt;40%), and low systolic blood pressure (adj RR, 2.70; 95% CI, 1.14 to 6.16; &amp;lt;100 mmHg vs. &amp;gt;121 mmHg) were the strongest predictors of major in-hospital bleeds in SPUM-ACS. These findings were similarly observed in AMIS Plus. Conclusion The CRUSADE score overestimates bleeding risk in NSTE-ACS. Among all 8 score variables, signs of heart failure, low hematocrit, and low systolic blood pressure are the strongest predictors of major in-hospital bleeds in contemporary patients with NSTE-ACS. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Swiss National Science FoundationSwiss Heart Foundation

Comparison of CRUSADE and ORBIT bleeding risk scores in prediction of mayor bleeding in pacients with acute coronary syndrome

Abstract Introduction Mayor bleeding is the most important complication of antithrombotic treatment in acute coronary syndrome (ACS) and is even associated with higher mortality. The CRUSADE scrore has been developed to predict mayor bleeding in ACS and is one of the most used. however, it has a moderate predictive capacity and is relatively complex to calculate at the patient's bedside. On the other hand, different bleeding risk scores have been developed for atrial fibrillation witch have also been evaluated for ACS, for example HAS-BLED. Recently, the NICE guidelines suggest using the Orbit Bleeding score (ORBIT) to assess the risk of bleeding in atrial fibrillation due to its greater predictive capacity. Its usefulness in the context of ACS has been little studied. Purpose The aim of the study is to evaluate the usefulness of the ORBIT to predict major bleeding in patients with ACS compared to the CRUSADE Methods A obserbational retrsopective study was performed. Patients with diagnostico ACS in two coronary units of Argentina were included. All of them, received antocoagulation as a antithrombitic treatment. The CRUSADE and ORBIT scores were calculated with the clinical data on admission. The primary point of major bleeding, defined as a BARC classification 3 or 5, was analyzed. Multivariate analysis was performed by logistic regression. To establish the discrimination capacity of the scores, the area under the ROC curve (AUC) was evaluated and the comparison between the curves was carried out using the chi-square area homogeneity test. Results A total of 880 patients were included (68% with non-ST elevation ACS and 32% with ST elevation), the mean of age was 68±11 years and 35% were women. As antithrombotic treatment, 100% received aspirin, 96.3% received P2Y12 receptor inhibitors, 100% received anticoagulation with enoxaparin, and 9.5% received fibrinolytics. The primary end point of major bleeding occurred in 3.4% (n=30). In univariate analysis both CRUSADE and ORBIT were predictors of mayor bleeding, but in multivariate analysis only ORBIT was independent predictor of mayor bleeding. (ORBIT OR: 2.46 (95% CI 1,61 to 3,97), P&amp;lt;0.001. The table shows the univariate and multivariate analysis. The AUC of CRUSADE was 0.68 (95% CI 0.57–0.80) and the ORBIT was 0.80 (95% CI 0.72–0.90). The ORBIT score presented a higher AUC than the CRUSADE (p=0.03). See Figure 1. Conclusion The Orbit score was an independent predictor of major bleeding in patients with ACS, presenting a better predictive capacity than the CRUSADE. Funding Acknowledgement Type of funding sources: None.

Temporal trends in the treatment and outcomes of patients with acute coronary syndrome according to bleeding risk

Abstract Background High bleeding risk is associated with adverse clinical outcomes in patients with ACS. We aimed to evaluate temporal trends in the treatment and outcomes of ACS patients according to bleeding risk. Methods Included were ACS patients enrolled in the ACSIS survey. Bleeding risk was calculated using the CRUSADE score. Patients were divided into 3 groups according to enrolment period: early (2002–2004), mid (2006–2010) and recent (2012–2018). Each group was further divided into 3 sub-groups according to bleeding risk (low, intermediate and high). The primary endpoints were 30-day MACE and 1-year all-cause mortality. Results Included were 13,058 ACS patients. Patients at high bleeding risk were more frequently treated with guideline-based medications and coronary revascularization regardless of enrollment period. ACS patients at high bleeding risk had higher rates of 30-day MACE and 1-year all-cause mortality in all enrolment periods. Among patients enrolled in early period, 30-day MACE rates were 10.8%, 17.5% and 24.3% (p&amp;lt;0.001), Among patients enrolled in mid period, 30-day MACE rates were 7.7%, 13.4% and 23.5% (p&amp;lt;0.001), and for patients enrolled in recent period, 30-day MACE rates were 5.7%, 8.6% and 16.2%, (p&amp;lt;0.001) in low, moderate and high bleeding risk group, respectively. Furthermore, among patients enrolled in early period, 1-year all-cause mortality rates were 2%, 7.7% and 23.6% (p&amp;lt;0.001), Among patients enrolled in mid period, 1-year all-cause mortality rates were 1.5%, 7.2% and 22.1% (p&amp;lt;0.001), and for patients enrolled in recent period, 1-year all-cause mortality rates were 2.1%, 6% and 22.4%, (p&amp;lt;0.001) in low, moderate and high bleeding risk group, respectively. These differences remained significant following a multivariate analysis. Conclusions Despite the improvement in the treatment of ACS patients in recent years, high bleeding risk remains a very strong predictor of adverse clinical outcomes. Funding Acknowledgement Type of funding sources: None.

Utility of pulmonary echography with a handheld ultrasound device in patients with acute coronary syndrome.

The objectives of this study are to establish the usefulness of lung ultrasound with a handheld device to predict the risk of developing heart failure with the need for mechanical ventilation (MV) in acute coronary syndrome (ACS). This is a prospective study of consecutive patients admitted because of ACS-type myocardial infarction, without data of HF at admission in a tertiary hospital, between February 2017 and February 2018. Lung ultrasounds were performed with a handheld cardiologic device in the first 24h, and defined as echo-positive (PE+) when exams revealed 3 or more B-lines in 2 or more bilateral quadrants. We related this finding to the need for MV during admission. We included 119 patients (65.1 ± 12.8year; 75.6% male, 24.4% female; 87.4% in Killip class I, 12.6% in Killip class II). Pulmonary echography was positive (PE+) in 21 patients (17.6%). The sensitivity of PE+ to predict MV was 93.3%, the specificity 93.3%, and the area under the curve 0.93. In Cox regression analysis adjusted by CRUSADE score and Killip class, PE+ patients had a hazard ratio of 64.55 (CI 7.87; 529.25, p < 0.001) of needing MV. PE+ was associated with more frequent use of inotropes and mortality. Pulmonary ultrasonography with a handheld echocardiograph was predictive of severe heart failure and the need for mechanical ventilation in ACS with high specificity and sensitivity.

In-Hospital Bleeding and Mortality in Acute Coronary Syndrome Patients Treated with Tirofiban and Potent P2Y12 Inhibitors.

In this study, we aimed to determine whether potent agents affect in-hospital bleeding and mortality compared to clopidogrel in patients with the acute coronary syndrome in whom tirofiban and P2Y12 inhibitor are used together. Patients who were treated interventionally between 2015 and 2020 and were using tirofiban were retrospectively screened. Clinical, laboratory, and angiographic findings were obtained from the hospital database. Patients were analyzed by dividing them into clopidogrel and prasugrel/ticagrelor groups. Acute coronary syndrome patients (n = 227) who were treated interventionally were included in this retrospective study. Clopidogrel was given to 93 (41%), ticagrelor to 112 (49.3%), and prasugrel to 22 of the patients (9.7%). Compared to the ticagrelor/prasugrel group, the clopidogrel group was older and more were women, and the history of hypertension and previous coronary artery disease was higher (P, respectively: <.001; .001; .008; .0045). The creatinine value was higher, the basal hemoglobin was lower, and the GRACE (Global Registry of Acute Coronary Events) and CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines) scores were higher (P, respectively: .026; .002; .002; <.001). The in-hospital bleeding rate was signifi- cantly higher in the clopidogrel group (P < .001). Although the in-hospital mortality rate was higher, it was not statistically significant (P = .07). Regression analysis showed that GRACE score and gender were associated with in-hospital mortality (P < .001; P=.031, respectively), and only age was associated with in-hospital bleeding (P < .001). No relationship was found with P2Y12 inhibitor. In our study, we found that the combined use of potent P2Y12 inhibitor with tiro- fiban in acute coronary syndrome patients treated interventionally was not different from the use of clopidogrel in terms of in-hospital bleeding and mortality.

Age shock index, a better predictor of prognosis for our patients?

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Shock is the main cause of in-hospital mortality in the setting of the Acute Coronary Syndromes (ACS). Shock Index (SI) Has been propposed as an useful predictor of shock and prognosis of the patients admitted because of an ACS. Not only this, a new index, derived from the previous one, which is known as Age Shock Index (ASI) seems to be even more accurate when evaluating these patients. Objetive Our first aim is to test if ASI is more accurate than SI to predict the occurrence of shock in patients admitted to the hospital with the diagnosis of ACS. Our second aim is to check if ASI is more accurate than SI, GRACE score and CRUSADE score to predict the in-hospital mortality of patients admitted to a hospital with the diagnosis of ACS and the presence of shock in the moment of the admission. Material and methods Observational, retrospective and single-center study including patients admitted to a Coronary Critical Care Unit (CCCU) between July 2.011 and March 2.021. ASI was calculated with the following formula: (heart rate x age) / systolic blood pressure. We calculated receptor-operative curves (ROC) of ASI and SI as predictors of shock for patients not presenting shock at the admision. We also calculated ROC of ASI, SI, GRACE and CRUSADE as predictors of in-hospital mortality of patients admitted in shock situation. We compared the area under the curve (AUC) between them. Results For the shock-prediction test we included 2.537 patients, who were admitted in Killip score &amp;lt;4. We found that ASI was a better predictor than SI, with a bigger AUC (0,76 (0,73–079) vs 0,72 (0,68–0,76), p&amp;lt;0,001, Picture 1) , being 44,6 the optimal cut point with better sensibility (0,67) and specificity (0,76). For the in-hospital mortality in shock patients prediction test we included 240 patients admitted in Killip score = 4. As we show in Picture 2, ASI was found to be a better predictor than SI and GRACE score, but not better than CRUSADE score, being 49,2 the optimal cut point with better sensibility (0,71) and specificity (0,53) Conclusion ASI is a better predictor of shock in patients admitted because of ACS than SI and also a better predictor of in-hospital mortality than SI and GRACE score in patients admitted because of ACS and a situation of shock at the admision. Althoug it was not better that CRUSADE score for this purpose, in favour of this index we highlight its simplicity of calculation, which, together with his good prediction capability, make it very useful in the acute setting.

Renal replacement therapy in acute coronary syndrome: what kind of patient requires it and what is its prognostic impact?

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The clinical acuity and medical complexity in contemporary tertiary center Cardiology Critical Care Units (CCCU) have heralded an increase in the prevalence of acute and chronic kidney disease. Consequently, renal replacement therapy (RRT) has become a rising technique in these units. Purpose Our aim was to analyze the baseline characteristics, complications and prognosis of patients with acute coronary syndrome (ACS) who required RRT during their admission, and to compare them with the characteristics of those patients who did not. Methods Retrospective observational analysis of registered ACS patients admitted to the CCCU of a tertiary center between January 2011 and January 2021. A comparative analysis was performed between those patients who required RRT during their admission, either due to chronic kidney disease (CKD) or peri-infarct acute kidney injury, and the remaining patients. Results 2596 patients were included in the analysis, showing the baseline characteristics listed in the table. A total of 53 (2%) required RRT during their admission. Patients requiring RRT more frequently presented ACS without ST elevation (69.8% vs 37.9%; p &amp;lt;0.001), multivessel disease (41.3% vs 17%; p &amp;lt;0.001) and a III or IV Killip-Kimbal (KK) score (38.5% vs 11%; p &amp;lt;0.001). During admission, they had a higher incidence of atrial fibrillation (AF) (34% vs 13.3%; p &amp;lt;0.001), bleeding (26.4% vs 10.5%; p &amp;lt;0.001), stroke (5.7% vs 1.2%; p 0.004), peri-infarct cardiorespiratory arrest (20.8% vs 10.2%; p 0.013) and in-hospital death (34% vs 5.9%; p &amp;lt;0.001). In the multivariate analysis performed, RRT was not an independent predictor of mortality when corrected for other risk factors (diabetes mellitus, GRACE and CRUSADE scores, STEACS, single vessel disease, or KK score on admission). Conclusions Patients admitted with ACS who required RRT had a higher risk profile, with a worse in-hospital prognosis and a higher incidence of complications. However, RRT was not found to be an independent predictor of mortality after adjusting for other variables.

Embolic versus non- embolic acute coronary syndrome. Baseline characteristics and presentation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Coronary embolism (CE) is a rare cause of acute coronary syndrome with current evidence from small case series. In our previous work (n=36), atrial fibrillation was the main risk factor and STEMI the most frequent presentation. Objetives In this analysis we compare baseline characteristics from an embolic versus a non-embolic cohort both with left anterior descending artery as culprit vessel. Methods Observational, retrospective descriptive study of patients admitted in our unit from July 2011 to march 2021 for acute coronary syndrome and diagnosed with CE (National Cerebral Cardiovascular Center Criteria). Comparative cohort data were analysed from ARIAM Andalucia Registry. Results 646 patients were analysed (19 embolic vs 627 non-embolic). 73.7% were women in the embolic group, 27% in the non-embolic one (p&amp;lt;0.05). Mean age 75±12 in the embolic cases versus 62±13 in non-embolic ones (p&amp;lt;0.05). 9.3% of patients had history of ischemic events and there was more previous heart failure in the embolic cohort (21.1% vs 3.0%, p&amp;lt;0.05%). Smoking was more frequent in the non-embolic group (43.5% vs 5.3%, p&amp;lt;0.05), insulin-dependent diabetes mellitus was more prevalent in the embolic cohort (21.1% vs 6.1%, p&amp;lt;0.05). There were no differences in other cardiovascular risk factors. AF and anticoagulation therapy were more frequent in the embolic cohort (31.6% vs 6.2%, p&amp;lt;0.05; 31.6% vs 5%, p&amp;lt;0.05). Time to first medical attention was not significantly shorter in the embolic group (95±80min vs 503±3278min, p&amp;gt;0.05). De novo AF was more frequent in the embolic group (31.6% vs 0.8%, p=0.02). GRACE and CRUSADE scores values were higher in embolic patients (162±31 vs 145±40, p=0.042; 45±10 vs 23±23, p=0.001). Conclusions CE is an infrequent entity. Our data suggest that in STEMI, elder women patients, with atrial fibrillation, insulin-dependent diabetes mellitus and not smoking, and with short delay to first medical attention, should rise the suspiction of this fenomenon.