Predicting Bleeding Complication In Patients Undergoing Stent Implantation And Subsequent Dual Antiplatelet Therapy Research Articles

External validation of the PRECISE-DAPT score in a large nationwide population of myocardial infarction patients: a SWEDEHEART study

Abstract Background/Introduction Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with stent placement in myocardial infarction (MI) patients has improved ischemic outcomes but increased the risk of bleeding. The PRECISE-DAPT (Predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy) score has been implemented in recent guidelines to tailor the duration of DAPT based on each patient's individual risk profile. However, to date it has only been externally validated on small data samples or exclusively for subgroups of PCI treated MI patients. Purpose To assess the performance of the PRECISE-DAPT score in a nationwide cohort of MI patients undergoing PCI with subsequent DAPT. This will be the world's largest validation of the PRECISE-DAPT score in approximately 20.000 unique real-world MI patients. Methods Data from the Swedish Websystem for Enhancement of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART) registry on MI patients treated with DAPT after PCI between 2008 and 2016 in Sweden were obtained and merged with the Swedish Patient Registry as well as the Prescribed Drugs Registry that holds data from all Swedish pharmacies. The ability of PRECISE-DAPT to predict bleeding and ischemic outcomes in relation to DAPT duration was determined. Results Results are to be announced. Conclusions Whether the PRECISE-DAPT score can be validated or not in a large nationwide cohort of MI patients in relation to DAPT duration, has the potential to impact current DAPT guidelines and clinical decision making in everyday practice. Further results and conclusions are to be announced. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): Märta Winkler's research foundation and Thorsten Westerström's research foundation

Bleeding risk in patients with acute coronary syndrome in a Turkish population: Results from the Turkish Acute Coronary Syndrome Registry (TACSER) study.

Bleeding is one of the most important causes of mortality in patients with acute coronary syndrome (ACS). This study therefore aimed to investigate bleeding risk in patients with ACS who were scheduled to receive dual antiplatelet therapy (DAPT) in Turkey. This was a multicentre, observational, cross-sectional cohort study. The study population included 963 patients with ACS from 12 centres in Turkey. We used the Predicting Bleeding Complication in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy (PRECISE-DAPT) score to predict the bleeding risk for all the patients. The patients were divided into high (≥25) or low (˂25) bleeding risk groups based on their PRECISE-DAPT scores. The mean PRECISE-DAPT score was 21.9. Overall, 32.2% of the patients had high PRECISE-DAPT scores (≥25). Compared with the male patients, the female patients had higher PRECISE-DAPT scores (28.2±15.7 vs 18.4±13.6, P˂.001). Among the females, the rate of patients with a PRECISE-DAPT score ≥25 was 53%, while among the male patients, the score occurred at a rate of 22%. The female patients had lower haemoglobin (Hb) levels than the male patients (12.1±1.7 vs 13.8±1.9, P˂.001) and lower creatinine clearance (70.7±27.5 vs 88.7±26.3, P˂.001). The in-hospital bleeding rates were higher among the patients with high PRECISE-DAPT scores than among those who did not have high scores. Furthermore, the patients with high PRECISE-DAPT scores had a higher in-hospital mortality rate compared with those with low PRECISE-DAPT scores (1% vs 0%, P=.11). The mean PRECISE-DAPT score was high among the patients with ACS in this study, indicating that the bleeding tendency was high. This study showed that the PRECISE-DAPT score may help physicians determine the type and duration of DAPT, especially in patients with ACS in Turkey.

The clinical value of the PRECISE-DAPT score in predicting long-term prognosis in patients with acute myocardial infarction

BackgroundThe predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score predicts the risk of bleeding in patients treated with dual antiplatelet therapy after percutaneous coronary intervention. Although the PRECISE-DAPT score is expected to be useful beyond its original field, long-term prognostic value of this score in patients with acute myocardial infarction (AMI) remains unclear. In the current study, we aimed to investigate the performance of the PRECISE-DAPT score in predicting the long-term prognosis in patients with AMI. Methods and resultsConsecutive 552 patients with AMI, who had been discharged from our institution, were enrolled. We divided the patients into three groups, based on their PRECISE-DAPT scores: the low (PRECISE-DAPT < 17), intermediate (17–24) and high (≥25) score groups. Kaplan-Meier analysis (mean follow-up 1424 days) revealed that all-cause mortality increased most steeply in the high score group followed by the intermediate and low score groups (P < 0.001). After adjusting for possible confounding factors, mortality of the intermediate or high score groups were higher than those of low score group (HR 2.945, 95% CI 1.182–7.237, P = 0.020, and HR 5.567, 95% CI 2.644–11.721, P < 0.001, respectively). ConclusionsIn patients with AMI, a high PRECISE-DAPT score was associated with higher long-term all-cause mortality. PRECISE-DAPT score is useful for predicting all-cause mortality, as well as risk stratification of bleeding.

P4791Performance of the HAS-BLED, ATRIA, and PRECISE-DAPT Bleeding Risk Scores in Atrial Fibrillation Patients Using Antiplatelet Agents or Oral Anticoagulants

Abstract Background Various bleeding risk scores have been proposed to assess the risk of bleeding in atrial fibrillation (AF) patients undergoing anticoagulation. PRECISE DAPT score has been developed to assess the out-of hospital bleeding risk in patients receiving dual antiplatelet therapy (DAPT). Our objective was to compare the predictive performance between the HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile International Normalized Ratio, Elderly, Drugs/Alcohol), ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation), and PRECISE-DAPT (Predicting Bleeding Complication in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet therapy) score in AF patients using antiplatelet agents or anticoagulants Methods We recruited 1,114 consecutive AF patients (51% male; median age, 71 years) receiving antiplatelet agents or oral anticoagulants from January 2014 through December 2018. Major bleeding was defined as according to the Bleeding Academic Research Consortium (BARC) criteria (type 3 or 5: hemodynamic instability, need for transfusion, drop in hemoglobin ≥3 g, and intracranial, intraocular or fatal bleeding). The performance of risk scores were assessed by C-statistic. Results Bleeding events occurred in 135 patients (12.1%) during 30 days, and 72 patients (6.5%) from 30 days till 1-year follow-up. Based on the C-statistic, PRECISE-DAPT score (AUC: 0.72, 95% CI: 0.69–0.75) had a good performance, significantly better than HAS-BLED (AUC: 0.64, 95% CI: 0.61–0.67) (p=0.008) or ATRIA scores (AUC: 0.57, 95% CI: 0.54–0.60) (p&lt;0.001) for 30-days bleeding prediction. Also, PRECISE-DAPT score had a good C-statistic (AUC: 0.72, 95% CI: 0.69–0.75) for 1-year bleeding events compared with HAS-BLED (AUC: 0.64, 95% CI: 0.60–0.67) (p=0.02) or ATRIA (AUC: 0.61, 95% CI: 0.58–0.65) (p=0.01). ROC curve for bleeding Conclusions The PRECISE-DAPT score has been used for assessing bleeding events during DAPT. Also, the PRECISE-DAPT score predicted bleedings better than HAS-BLED or ATRIA scores in AF patients. So, the PRECISE-DAPT score may be considered as bleeding risk score during DAPT or oral anticoagulation in clinical practice.

Use of PRECISE-DAPT Score and Admission Platelet Count to Predict Mortality Risk in Patients With Acute Coronary Syndrome.

The PREdicting bleeding Complications In patients undergoing Stent implantation and subsEquent Dual Antiplatelet Therapy (PRECISE-DAPT) score has been validated to predict bleeding complications in patients undergoing stent implantation and dual antiplatelet therapy. This score does not include the platelet count (PC), which has been shown to be an independent marker of mortality in patients with acute coronary syndrome (ACS). We assessed the role of the PRECISE-DAPT score calculated on admission for mortality risk prediction and evaluated whether the predictive accuracy of this score improved by adding the PC. In a retrospective cohort study of 1000 patients with ACS, after adjustment for relevant covariates, a PRECISE-DAPT score ≥25 was independently associated with mortality (hazard ratio [HR]: 7.91; 95% confidence interval [CI]: 4.37-14.30). When this score was combined with PC, compared to patients with PRECISE-DAPT <25 and PC ≥150 × 109/L, the adjusted HR was 7.2 (95% CI 2.4-21.6) for those with PRECISE-DAPT <25 and PC <150 × 109/L; 10.7 (95% CI: 5.2-21.9) for those with PRECISE-DAPT ≥25 and PC ≥150 × 109/L; and 17.9 (95% CI 7.0-45.4) for those with PRECISE-DAPT ≥25 and PC <150 × 109/L. Selecting thresholds for high-risk designation, the PRECISE-DAPT score integrated with PC had a higher prediction value, compared to the PRECISE-DAPT and Global Registry of Acute Coronary Events scores.

The Predictive Value of PRECISE-DAPT Score for In-Hospital Mortality in Patients With ST-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention.

The PREdicting bleeding Complications In patients undergoing Stent implantation and subsEquent Dual Anti-Platelet Therapy (PRECISE-DAPT) score predicts the bleeding risk in patients treated with dual antiplatelet treatment after primary percutaneous coronary intervention (pPCI). This study aimed to determine the predictive value of the admission PRECISE-DAPT score for in-hospital mortality in patients with ST elevation myocardial infarction (STEMI) treated with pPCI. Of the 1418 patients enrolled, the study population was divided into 2 groups: PRECISE-DAPT score ≥25 and PRECISE-DAPT score <25. The primary goal was to determine the incidence of in-hospital all-cause mortality. In-hospital mortality was significantly higher in patients whose PRECISE-DAPT score ≥25 compared with the patients whose PRECISE-DAPT score <25 (9.4 vs 0.9%; P < .001, respectively). Both univariate and multivariate Cox proportional hazard analyses showed that the PRECISE-DAPT score is independently associated with in-hospital mortality (hazards ratio [HR]: 1.043, 95% confidence interval [CI]: 1.003-1.084; P = .035; and HR: 1.026, 95% CI: 1.004-1.048; P = .021, respectively). A pairwise comparison of receiver operating characteristic curves showed that the predictive value of the PRECISE-DAPT score with regard to in-hospital mortality was noninferior compared with the Thrombolysis in Myocardial Infarction risk score. The PRECISE-DAPT score may be a significant independent predictor of in-hospital mortality in patients with STEMI treated with pPCI.

Blutungsrisiko unter dualer Plättchenhemmung – neuer Score verfügbar

Costa F et al. Derivation and validation of the predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score: a pooled analysis of individual-patient datasets from clinical trials. Lancet 2017; 389: 1025 – 1034

Derivation and validation of the predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score: a pooled analysis of individual-patient datasets from clinical trials

Dual antiplatelet therapy (DAPT) with aspirin plus a P2Y12 inhibitor prevents ischaemic events after coronary stenting, but increases bleeding. Guidelines support weighting bleeding risk before the selection of treatment duration, but no standardised tool exists for this purpose. A total of 14 963 patients treated with DAPT after coronary stenting-largely consisting of aspirin and clopidogrel and without indication to oral anticoagulation-were pooled at a single-patient level from eight multicentre randomised clinical trials with independent adjudication of events. Using Cox proportional hazards regression, we identified predictors of out-of-hospital Thrombosis in Myocardial Infarction (TIMI) major or minor bleeding stratified by trial, and developed a numerical bleeding risk score. The predictive performance of the novel score was assessed in the derivation cohort and validated in patients treated with percutaneous coronary intervention from the PLATelet inhibition and patient Outcomes (PLATO) trial (n=8595) and BernPCI registry (n=6172). The novel score was assessed within patients randomised to different DAPT durations (n=10 081) to identify the effect on bleeding and ischaemia of a long (12-24 months) or short (3-6 months) treatment in relation to baseline bleeding risk. The PRECISE-DAPT score (age, creatinine clearance, haemoglobin, white-blood-cell count, and previous spontaneous bleeding) showed a c-index for out-of-hospital TIMI major or minor bleeding of 0·73 (95% CI 0·61-0·85) in the derivation cohort, and 0·70 (0·65-0·74) in the PLATO trial validation cohort and 0·66 (0·61-0·71) in the BernPCI registry validation cohort. A longer DAPT duration significantly increased bleeding in patients at high risk (score ≥25), but not in those with lower risk profiles (pinteraction=0·007), and exerted a significant ischaemic benefit only in this latter group. The PRECISE-DAPT score is a simple five-item risk score, which provides a standardised tool for the prediction of out-of-hospital bleeding during DAPT. In the context of a comprehensive clinical evaluation process, this tool can support clinical decision making for treatment duration. None.