Predictors Of Bleeding Complications Research Articles

152: Predictors of bleeding complications during interfacility transport of ECMO patients

152: Predictors of bleeding complications during interfacility transport of ECMO patients

Predicting New-Onset Atrial Fibrillation in Patients with Coronary Artery Bypass Graft: the Precise-Dapt Score

<b>Aim:</b> Postoperative new-onset atrial fibrillation (POAF) after isolated coronary artery bypass graft surgery (CABG) is associated with adverse events. The Predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score is used to predict the bleeding risk after dual antiplatelet therapy and has been associated with arrhythmias in recent years. Therefore, the present study sought to investigate the association between the PRECISE-DAPT score and POAF after coronary artery bypass graft surgery.<br /> <b>Materials and Methods:</b> 350 patients who underwent CABG were retrospectively screened. After exclusion criteria, 135 patients were included in the study. A total of 135 patients who underwent on-pump CABG were divided into two groups: patients with POAF and those without POAF. The PRECISE-DAPT score was calculated for each patient, and intergroup comparisons of the calculated scores were performed.<br /> <b>Results:</b> POAF was detected in 66 patients out of 135. Patients with POAF had longer hospital stays. PRECISE-DAPT score was higher in the patients with POAF compared to the patients without POAF (p<0.001). PRECISE-DAPT score was determined to be a predictor of POAF after CABG (odds ratio [OR]: 1.305; 95% confidence interval [CI]: 1.268–2.030; p<0.001). The PRECISE-DAPT score for POAF risk had a sensitivity of 60% and a specificity of 79% at cut-off values of 14.5 and above.<br /> <b>Conclusion:</b> An increased PRECISE-DAPT score may be used as a predictive score for POAF that may develop during hospital stay after on-pump CABG.

Abbreviated Versus Standard Dual Antiplatelet Therapy Times After Percutaneous Coronary Intervention in Patients With High Bleeding Risk With Acute Coronary Syndrome: Insights From the SWEDEHEART Registry.

Dual antiplatelet therapy (DAPT) reduces ischemic events but increases bleeding risk, especially in patients with high bleeding risk (HBR). This study aimed to compare outcomes of abbreviated versus standard DAPT strategies in patients with HBR with acute coronary syndrome undergoing percutaneous coronary intervention. Patients from the SWEDEHEART (Swedish Web-system for Enhancement and Development of Evidence-Based Bare in Heart Disease Evaluated According to Recommended Therapies) registry with at least 1 HBR criterion who underwent percutaneous coronary intervention for acute coronary syndrome were identified and included. Patients were divided into 2 groups based on their planned DAPT time at discharge: 12-month DAPT or an abbreviated DAPT strategy and matched according to their prescribed P2Y12 inhibitor at discharge. The primary outcome assessed was time to net adverse clinical events at 1 year, which encompassed cardiac death, myocardial infarction, ischemic stroke, or clinically significant bleeding. Time to major adverse cardiovascular events and the individual components of net adverse clinical events were considered secondary end points. A total of 4583 patients were included in each group. The most frequently met HBR criteria was age older than 75 years (65.6%) and Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy score ≥25 (44.6%) in the standard DAPT group and oral anticoagulant therapy (79.6%) and age 75 years and older (55.2%) in the abbreviated DAPT group. There was no statistically significant difference in net adverse clinical events (12.9% versus 13.1%; hazard ratio [HR], 0.99 [95% CI, 0.88-1.11], P=0.83), major adverse cardiovascular events (8.6% versus 7.9%; HR, 1.08 [95% CI, 0.94-1.25]), or their components between groups. The results were consistent among all of the investigated subgroups. In patients with HBR undergoing percutaneous coronary intervention due to acute coronary syndrome, abbreviated DAPT was associated with comparable rates of net adverse clinical events and major adverse cardiovascular events to a DAPT duration of 12 months.

Predictors of Bleeding Complications During Catheter-directed Thrombolysis for Peripheral Arterial Occlusions

Predictors of Bleeding Complications During Catheter-directed Thrombolysis for Peripheral Arterial Occlusions

Predictors of bleeding complications during catHeter-dirEcted thrombolysis for peripheral arterial occlusions (POCHET).

The risk of major bleeding complications in catheter directed thrombolysis (CDT) for acute limb ischemia (ALI) remains high, with reported major bleeding complication rates in up to 1 in every 10 treated patients. Fibrinogen was the only predictive marker used for bleeding complications in CDT, despite the lack of high quality evidence to support this. Therefore, recent international guidelines recommend against the use of fibrinogen during CDT. However, no alternative biomarkers exist to effectively predict CDT-related bleeding complications. The aim of the POCHET biobank is to prospectively assess the rate and etiology of bleeding complications during CDT and to provide a biobank of blood samples to investigate potential novel biomarkers to predict bleeding complications during CDT. The POCHET biobank is a multicentre prospective biobank. After informed consent, all consecutive patients with lower extremity ALI eligible for CDT are included. All patients are treated according to a predefined standard operating procedure which is aligned in all participating centres. Baseline and follow-up data are collected. Prior to CDT and subsequently every six hours, venous blood samples are obtained and stored in the biobank for future analyses. The primary outcome is the occurrence of non-access related major bleeding complications, which is assessed by an independent adjudication committee. Secondary outcomes are non-major bleeding complications and other CDT related complications. Proposed biomarkers to be investigated include fibrinogen, to end the debate on its usefulness, anti-plasmin and D-Dimer. The POCHET biobank provides contemporary data and outcomes of patients during CDT for ALI, coupled with their blood samples taken prior and during CDT. Thereby, the POCHET biobank is a real world monitor on biomarkers during CDT, supporting a broad spectrum of future research for the identification of patients at high risk for bleeding complications during CDT and to identify new biomarkers to enhance safety in CDT treatment.

Diagnostic Value of the Pediatric Bleeding Questionnaire in Prediction of Bleeding in Minor Surgery.

Preoperative coagulation tests have not been shown to be effective in predicting bleeding complications. The Pediatric Bleeding Questionnaire (PBQ) is a proven and sensitive tool for diagnosing children with a predisposition to bleeding. The aim of this study was to evaluate the usefulness of PBQ as a preoperative screening tool for the prediction of bleeding after minor surgical interventions. Preoperative coagulation tests and PBQ were performed in all patients who underwent minor surgery. The postoperative bleeding status was evaluated and then compared with the coagulation tests and PBQ of the patients. Evaluation was made of a total of 706 patients, comprising 91.2% males and 8.8% females, with a mean age of 4.8 years (median: 4y, QR: 1 to 7y). Prolongation in coagulation tests was observed in 131 (18.5%) patients. Repeated tests in 116 patients were within the normal range, and 5 patients received treatment. Postoperative bleeding occurred in 4 (0.5%) patients. The relationship between coagulation tests and postoperative bleeding was not significant. PBQ was found to be ≥2 in 14 patients, but none of these patients had postoperative bleeding. No significant relationship was found between postoperative bleeding status and PBQ ( p :0.77). The sensitivity, specificity, positive predictive, and negative predictive values of PBQ were 0%, 98%, 0%, and 97.4%, respectively. The results of this study demonstrated that neither coagulation tests nor PBQ will be sufficient to predict bleeding after minor surgery, that prolongation in coagulation tests does not always indicate a bleeding tendency, and that bleeding history should also be recorded in detail.

Comparison of Discriminative Ability of Bleeding Risk Criteria and Scores for Predicting Short- and Mid-Term Major Bleeding Events in Patients Undergoing Percutaneous Coronary Intervention.

Background: This study aimed to compare the discriminative ability of the Japanese Version of High Bleeding Risk (J-HBR), Academic Research Consortium for High Bleeding Risk (ARC-HBR), and Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy (PRECISE-DAPT) scores for predicting major bleeding events. Methods and Results: Between January 2017 and December 2020, 646 consecutive patients who underwent successful percutaneous coronary intervention (PCI) were enrolled. We scored the ARC-HBR and J-HBR criteria by assigning 1 point to each major criterion and 0.5 point to each minor criterion. The primary outcome was major bleeding events, defined as Bleeding Academic Research Consortium type 3 or 5 bleeding events. According to the J-HBR, ARC-HBR, and PRECISE-DAPT scores, 428 (66.3%), 319 (49.4%), and 282 (43.7%) patients respectively had a high bleeding risk. During the follow-up period (median, 974 days), 44 patients experienced major bleeding events. The area under the curve (AUC) using the time-dependent receiver operating characteristic curve for major bleeding events was 0.84, 0.82, and 0.83 within 30 days and 0.86, 0.83, and 0.80 within 2 years for the J-HBR, ARC-HBR, and PRECISE-DAPT scores, respectively. The AUC values did not differ significantly among the 3 bleeding risk scores. Conclusions: The J-HBR score had a discriminative ability similar to the ARC-HBR and PRECISE-DAPT scores for predicting short- and mid-term major bleeding events.

The predictive value of PRECISE-DAPT score for long-term mortality in patients with acute coronary syndrome complicated by cardiogenic shock.

Besides its primary clinical utility in predicting bleeding risk in patients with acute coronary syndrome (ACS), the PRECISE-DAPT (Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Anti-Platelet Therapy) score may also be useful for predicting long-term mortality in ACS patients presenting with cardiogenic shock (CS) since several studies have reported an association between the score and certain cardiovascular conditions or events. The aim of the present study was to evaluate the utility of the PRECISE-DAPT score for predicting the long-term all-cause mortality in patients (n = 293) with ACS presenting with CS. The PRECISE-DAPT score was calculated for each patient who survived in hospital, and the association with long-term mortality was studied. Median follow-up time was 2.7years. The performance of the final model was determined with measurements of its discriminative power (Harrell's and Uno'sC indices and time-dependent area under the receiver operating characteristic curve [AUC]) and predictive accuracy (coefficient of determination [R2] and likelihood ratio χ2). Hazard ratios (HRs) were used to assess the relationship between the variables of the model and long-term all-cause death. All-cause death occurred in 197 patients (67%). There was apositive association between the PRECISE-DAPT score (change from 17 to38 was associated with anHR of 2.42 [95% CI: 1.59-3.68], R2 = 0.209, time-dependent AUC = 0.69) and the risk of death such that in the adjusted survival curve, the risk of mortality increased as the PRECISE-DAPT score increased. The PRECISE-DAPT score may be auseful easy-to-use tool for predicting long-term mortality in patients with ACS complicated by CS.

Meta-analytic analysis of the role of hemostatic evaluation in optimizing surgical results

Introduction: Pre-surgical clinical assessment constitutes an essential practice in internal medicine, focused on the identification of risk factors to reduce perioperative morbidity and mortality.Objective: This study seeks to critically evaluate the effectiveness of preoperative coagulation tests to predict bleeding complications in elective non-cardiac surgeries, in order to validate their clinical relevance and adjust practices to real needs based on solid evidence.Method: A meta-analysis approach was employed to synthesize data from multiple studies examining the correlation between preoperative coagulation testing and intra- and postoperative bleeding complications. Study selection was based on rigorous criteria to include only those with patients without a history of hematological diseases who underwent elective non-cardiac surgeries.Results: The results indicate that alterations in coagulation tests are not significantly associated with an increased risk of hemorrhagic complications, as evidenced by a relative risk (RR) of less than one. This suggests that routine performance of these tests in the study population may not be necessary and does not contribute significantly to the safety of the surgical patient.Conclusions: The study supports a review of clinical guidelines to reduce unnecessary defensive medical practices and encourage evidence-based decisions. It is recommended to limit preoperative coagulation testing to patients with identifiable risk factors or clinical manifestations of hemostatic disorders, avoiding widespread and unsubstantiated procedures that overload health systems without improving clinical outcomes.

Meta-analytic analysis of the role of hemostatic evaluation in optimizing surgical results

Introduction: pre-surgical clinical assessment constitutes an essential practice in internal medicine, focused on the identification of risk factors to reduce perioperative morbidity and mortality.Objective: this study seeks to critically evaluate the effectiveness of preoperative coagulation tests to predict bleeding complications in elective non-cardiac surgeries, in order to validate their clinical relevance and adjust practices to real needs based on solid evidence.Method: a meta-analysis approach was employed to synthesize data from multiple studies examining the correlation between preoperative coagulation testing and intra- and postoperative bleeding complications. Study selection was based on rigorous criteria to include only those with patients without a history of hematological diseases who underwent elective non-cardiac surgeries.Results: the results indicate that alterations in coagulation tests are not significantly associated with an increased risk of hemorrhagic complications, as evidenced by a relative risk (RR) of less than one. This suggests that routine performance of these tests in the study population may not be necessary and does not contribute significantly to the safety of the surgical patient.Conclusions: the study supports a review of clinical guidelines to reduce unnecessary defensive medical practices and encourage evidence-based decisions. It is recommended to limit preoperative coagulation testing to patients with identifiable risk factors or clinical manifestations of hemostatic disorders, avoiding widespread and unsubstantiated procedures that overload health systems without improving clinical outcomes

Post-menopause women show increased levels in risk prediction scores with age as dependent variable

Abstract Background Men and women differ in outcome after percutaneous coronary intervention (PCI). However, frequently used scores for ischemic risk prediction in patients with cardiovascular disease do not include sex related factors. In this study, we aimed to analyze sex related differences in risk score prediction in patients after PCI in dependence from age-determined menopause. Methods In this mono-center analysis, we compared frequently used risk prediction scores for post PCI patients (GRACE [Global Registry of Acute Coronary Events], PRECISE-DAPT [PREdicting bleeding Complications In patients undergoing Stent implantation and subsEquent Dual Antiplatelet Therapy], NCDR-mortality and PARIS [Patterns of Non-Adherence to Anti-Platelet Regimen in Stented Patients]-thrombotic score) in male versus female post PCI patients in dependence from menopause (age determined) and age itself. Three-year follow-up was conducted to assess the incidence of MACCE (major adverse cerebro- and cardiovascular events) including all-cause mortality, myocardial infarction and stroke. Receiver operating characteristic (ROC) analysis was conducted to analyze predictive capacity of each score. Results 1,001 patients post PCI were included (38% chronic coronary syndrome [CCS], 61% acute coronary syndrome [ACS]). Out of these, 765 were male and 306 were female. Women were slightly older (68.1±11.5 vs. 73.3±11.3 years, p<0.0001). Male and female patients did not differ in achieved levels of risk score below the age of 55. In contrast, in the subgroups >55 years, GRACE, PD-DAPT and NCDR Mortality scores were higher in woman compared to men (GRACE – 120.5±27.89 vs. 128.5±29.97, p<0.0001; PD-DAPT – 26.46±13.13 vs. 30.66±12.76, p<0.001; NCDR Mortality – 345.79±18.33 vs. 40.8±20.62, p<0.0001). Interestingly, PARIS thrombotic score was reduced (4.02±2.28 vs. 3.6±2.3, p=0.027). After Propensity score matching for age, GRACE, PD-DAPT and NCDR Mortality did no longer differ whereby PARIS thrombotic was reduced in female patients in this analysis as well. ROC revealed a moderate predictive capacity for MACCE for all scores in this post PCI cohort with a numerically higher predictive capacity for women (GRACEAUC – 0.625 vs. 0.662; PD-DAPTAUC 0.589 vs. 0.660, NCDR-mortalityAUC 0.625 vs. 0.667; PARIS-thromboticAUC 0.594 vs. 0.638). Conclusion In this single center analysis of post PCI patients with ACS and CCS, we could reveal that the GRACE, PD-DAPT and NCDR-mortality risk scores show higher values in post-menopause women compared to men whereby the PARIS-thrombotic score was reduced. We revealed age as major driver for this discrepancy. Moreover, women showed a numerically higher predictive accuracy for the occurrence of MACCE in line with the demonstrated worse outcome after PCI in several cohorts.

External validity of the PRECISE-DAPT score in patients undergoing PCI: a systematic review and meta-analysis.

To summarise the totality of evidence validating the Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy (PRECISE-DAPT) score, ascertaining its aggregate discrimination and validation power in multiple population subsets. We searched electronic databases from 2017 (PRECISE-DAPT proposal) up to March 2023 for studies that reported the occurrence of out-of-hospital bleedings according to the PRECISE-DAPT score in patients receiving DAPT following percutaneous coronary intervention (PCI). Pooled odds ratio (OR) with 95% confidence interval (CI) were used as summary statistics and were calculated using a random-effects model. Primary and secondary endpoints were the occurrence of any and major bleeding, respectively. A total of twenty-one studies and 67283 patients were included; 24.7% of patients (N=16603) were at high-bleeding risk (PRECISE-DAPT≥25) and when compared to those at low-bleeding risk, they experienced a significantly higher rate of any out-of-hospital bleeding (OR: 2.71; 95% CI: 2.24-3.29; p-value<0.001) and major bleedings (OR: 3.51; 95% CI: 2.71-4.55; p-value<0.001). Pooling data on c-stat whenever available, the PRECISE-DAPT score showed a moderate discriminative power in predicting major bleeding events at 1-year (pooled c-stat: 0.71; 95% CI: 0.64-0.77). This systematic review and meta-analysis confirms the external validity of the PRECISE-DAPT score in predicting out-of-hospital bleeding outcomes in patients on DAPT following PCI. The moderate discriminative ability highlights the need for future improved risk prediction tools in the field.

Bleeding risk and P2Y12-inhibitors in all-comer patients with ST-segment elevation myocardial infarction treated with percutaneous coronary intervention: a single-center cohort study.

To characterise and follow patients with ST-segment elevation myocardial infarction (STEMI) at HBR (high bleeding risk) according to the PRECISE-DAPT score (predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy), and to examine the use of P2Y12-inhibitors and subsequent risk of major adverse cardiovascular events (MACE) and bleeding. This single-center cohort study included 6179 consecutive STEMI patients who underwent percutaneous coronary intervention (PCI) at Copenhagen University Hospital, Rigshospitalet, between 2009-2016. Individual linkage to nationwide registries was conducted to obtain information on diagnoses, claimed drugs, and vital status. Of the 5532 (89.5%) patients with available PRECISE-DAPT scores, 33.0% were at HBR and more often elderly and female with more comorbidities than non-HBR patients. One-year cumulative incidence rates per 100 person-years were 8.7 and 2.1 for major bleeding and 36.8 and 8.3 for MACE in HBR and non-HBR patients, respectively. Among the 4749 (85.8%) patients who survived and collected a P2Y12-inhibitor≤7 days from discharge, 68.2% of HBR patients were treated with ticagrelor or prasugrel and 31.8% with clopidogrel, while 18.2% non-HBR patients were treated with clopidogrel. Adherence was high for all (>75% days coverage). The risk of MACE was lower in ticagrelor and prasugrel than clopidogrel-treated patients without differences in major bleeding. One-third of PCI-treated all-comer patients with STEMI were at HBR according to the PRECISE-DAPT score and more often treated with potent P2Y12-inhibitors instead of clopidogrel. Thus, ischaemic risk may be weighted over bleeding risk in STEMI patients at HBR.

The plasma concentration of ticagrelor and aspirin as a predictor of bleeding complications in Chinese ACS patients with dual antiplatelet therapy: A prospective observational study.

This study evaluated the association among the plasma concentration of ticagrelor, ARC124910XX, aspirin, and salicylic acid with the risk of recent bleeding in patients with the acute coronary syndrome. To this end, we developed an accurate model to predict bleeding. A total of 84 patients included in this study cohort between May 2021 and November 2021. The risk factors were identified by univariate and multivariate analyses, and statistically significant risk factors identified in the multivariate analysis were included in the nomogram. We used the calibration curve and the receiver operating characteristic (ROC) curve to verify the accuracy of the prediction model. Multivariable logistic analysis showed that ticagrelor concentration (OR: 2.47, 95%CI: 1.51-4.75, P=0.002), ST-segment elevation acute myocardial infarction (STEMI, OR: 32.2, 95%CI: 2.37-780, P=0.016), and lipid-lowering drugs (OR: 11.52, 95%CI: 1.91-110, P=0.015) were positively correlated with bleeding. However, ACEI/ARB (OR: 0.04, 95%CI: 0.004-0.213, P<0.001) was negatively correlated with bleeding. The receiver operating characteristic curve analysis (ROC) showed that ticagrelor concentration and these factors together predict the occurrence of bleeding (AUC=0.945, 95%CI: 0.896-0.994) and that ticagrelor concentration > 694.90 ng/mL is the threshold of bleeding concentration (AUC=0.696, 95%CI: 0.558-0.834). In patients with acute coronary syndrome treated with dual antiplatelet therapy, ticagrelor concentration > 694.90 ng/mL was an independent risk factor for bleeding (OR: 2.47, 95% CI: 1.51-4.75, P=0.002), but ARC124910XX and salicylic acid concentration did not affect bleeding risk (P>0.05).

E-49 | Moderate to High Precise-DAPT Score Is Associated With Increased Risk of Bleeding and Mortality in a Predominantly Hispanic Population

Bleeding is a major complication for patients on dual anti-platelet therapy (DAPT) post percutaneous coronary intervention (PCI). Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy (PRECISE-DAPT) score has been widely used inEurope for the prediction of bleeding during DAPT with a cut-off of ≥ 25 as high risk. We determined the predictive accuracy of PRECISE-DAPT scores in a predominantly Hispanic population. A retrospective single center cohort study was conducted with patients on DAPT post PCI between 2014 and 2021. PRECISE-DAPT score was assessed and classified into three categories (low: ≤17; moderate:18 to 24; high: ≥25). The primary endpoints were incidence of bleeding as evaluated using Bleeding Academic Research Consortium (BARC) ≥ 2 events and all-cause mortality. Kaplan Meier curve, log rank test and Cox proportional hazards models were performed. Receiver operating characteristic (ROC) curve analysis was performed to determine optimal cut-offs. Out of 829 patients(age 62 ± 12 years, 66% males, 78% Hispanic), 46 (5.5%) had BARC ≥ 2 bleeding complications and 38 (4.5%) had deaths after PCI for a mean follow up of 2.8 ± 2.4 years. Compared with low PRECISE-DAPT risk score, moderate and high-risk scores were associated with increased risk of bleeding (3.18%, 10.22%, and 7.69 %, respectively, p=0.002). Similarly, in comparison with low score, moderate and high score groups had higher incidence of all-cause mortality (2.12%, 6.57%, and 7.69% respectively, p<0.001). In the adjusted analysis, the combined moderate and high scores predicted higher risk of bleeding (hazard ratio [HR] 2.89; 95%CI: 1.47-5.71, p=0.002) and all-cause mortality (HR 5.78, 95%CI 2.41-13.83, p <.0001). A cut-off value ≥19 of the PRECISE-DAPT score classified bleeding (AUC=0.63; 95%CI: 0.55-0.71) and all-cause mortality (AUC=0.68; 95%CI: 0.60-0.77). Our results suggest moderate to high PRECISE-DAPT score was associated with the increased risk of bleeding and mortality in patients with DAPT post PCI in a predominantly Hispanic population with an optimal cut-off of ≥19 instead of 25.

Prediction of Bleeding by the PRECISE-DAPT Score in Patients with Carotid Artery Stenting

The predicting bleeding complications in patients undergoing stent implantation and the subsequent dual antiplatelet therapy (PRECISE-DAPT) score predicts the risk of bleeding in patients with dual antiplatelet therapy (DAPT) after percutaneous coronary interventions (PCIs). Patients with carotid artery stenting (CAS) are also treated with DAPT. In this study, we aimed to investigate the performance of the PRECISE-DAPT score in predicting bleeding in patients with CAS. Patients who had CAS between January 2018 and December 2020 were retrospectively enrolled. The PRECISE-DAPT score was calculated for each patient. The patients were divided into two groups based on their PRECISE-DAPT score: low < 25 and high ≥ 25. Bleeding and ischemia complications and laboratory data among the two groups were compared. A total of 120 patients with a mean age of 67.3 ± 9.7years were included. Forty-three patients had high PRECISE-DAPT scores, and 77 patients had low PRECISE-DAPT scores. Six patients developed bleeding events during the six-month follow-up, and five of them were in the PRECISE DAPT score ≥ 25 group. The difference between the two groups regarding bleeding events at six months was significant (P = 0.022). The PRECISE-DAPT score might be used for predicting the bleeding risk in patients with CAS, and the bleeding rate was significantly higher in patients with a PRECISE-DAPT score ≥ 25.

Prognostic Value of Machine‐Learning‐Based PRAISE Score for Ischemic and Bleeding Events in Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention

Background The PRAISE (Prediction of Adverse Events Following an Acute Coronary Syndrome) score is a machine-learning-based model for predicting 1-year all-cause death, myocardial infarction, and Bleeding Academic Research Consortium (BARC) type 3/5 bleeding. Its utility in an unselected Asian population undergoing percutaneous coronary intervention for acute coronary syndrome remains unknown. We aimed to validate the PRAISE score in a real-world Asian population. Methods and Results A total of 6412 consecutive patients undergoing percutaneous coronary intervention for acute coronary syndrome were prospectively included. The PRAISE scores were compared with established scoring systems (GRACE [Global Registry of Acute Coronary Events] 2.0, PRECISE-DAPT (Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy), and PARIS [Patterns of Non-Adherence to Anti-Platelet Regimen in Stented Patients]) to evaluate their discrimination, calibration, and reclassification. The risk of all-cause mortality (hazard ratio [HR], 12.24 [95% CI, 5.32-28.15]) and recurrent acute myocardial infarction (HR, 3.92 [95% CI, 1.76-8.73]) was greater in the high-risk group than in the low-risk group. The C-statistics for death, myocardial infarction, and major bleeding were 0.75 (0.67-0.83), 0.61 (0.52-0.69), and 0.62 (0.46-0.77), respectively. The observed to expected ratio of death, myocardial infarction, and major bleeding was 0.427, 0.260, and 0.106, respectively. Based on the decision curve analysis, the PRAISE score displayed a slightly greater net benefit for the 1-year risk of death (5%-10%) than the GRACE score did. Conclusions The PRAISE score showed limited potential for risk prediction in our validation cohort with acute coronary syndrome. As a result, new prediction models or model refitting are required with improved discrimination and accuracy in risk prediction.

PRECISE-DAPT and ARC-HBR Predict in-Hospital Outcomes in Patients Who Underwent Percutaneous Coronary Intervention

Bleeding events result in morbidity and mortality in patients who underwent percutaneous coronary intervention (PCI). There are limited data on the predicting bleeding complications in patients who underwent stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) and Academic Research Consortium for High Bleeding Risk (ARC-HBR) scores' ability to predict in-hospital outcomes in patients who underwent PCI. Consecutive patients who underwent PCI at tertiary centers from January 2016 to March 2018 were identified and the bleeding risk scores were calculated. The primary end point was the National Cardiovascular Data Registry-defined in-hospital bleeding stratified by low versus high predicted bleeding risk. The major and net adverse cardiovascular events were also examined. The discriminatory ability of the risk models was determined using receiver operating characteristic curves. Among 3,659 patients studied, the in-hospital major bleeding was 3.3% (n=121). The patients characterized as high bleeding risk by either criterion had significantly higher bleeding rates than those meeting the low-risk criteria (ARC-HBR 5.4% vs 3.3%, p <0.001; PRECISE-DAPT 5.8% vs 2.4%, p <0.001), and higher major adverse cardiovascular events and net adverse clinical events. These risk estimates showed moderate and similar predictive ability (ARC-HBR high-risk area under the receiver operating characteristic curve [AUC] 0.62, PRECISE-DAPT ≥25 AUC 0.61, p=0.49), with no incremental benefit to adding the estimates (AUC 0.60). The subgroup analysis revealed that women had higher bleeding rates than men (5.53% vs 2.39%, p <0.001); however, the predictive ability of the criteria were similar in women and men. The patients identified as having a high bleeding risk by the PRECISE-DAPT and the ARC-HBR criteria before PCI are at high risk for in-hospital bleeding and adverse outcomes independent of gender. The 2 scores have moderate predictive ability for bleeds. Further study is needed to determine strategies to reduce risk in this population.

The Relationship Between PRECISE-DAPT Score and Spontaneous Reperfusion of Infarct-Related Artery in Patients with ST-Segment Elevation Myocardial Infarction.

Spontaneous reperfusion (SR) presence and a low PREdicting bleeding Complications In patients undergoing Stent implantation and subsEquent Dual Anti Platelet Therapy (PRECISE-DAPT) score in patients with acute coronary syndrome have been associated with favorable clinical outcomes. This study aimed to investigate the relationship between SR and this score. The study included 436 patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI). Thrombolysis in myocardial infarction (TIMI) III blood flow presence in the infarct-related artery (IRA) before primary percutaneous coronary intervention (PCI) was defined as SR. Patients were categorized into two groups based on the presence (n = 49) or absence (n = 387) of SR. The PRECISE-DAPT score was computed for each patient using the web-based calculator. The group with SR had a lower frequency of hyperlipidemia and a higher ejection fraction (EF) at admission. Conversely, the group without SR presented with higher values of glucose, troponin, creatine kinase-myocardial band (CK-MB), and PRECISE-DAPT score. The no-reflow phenomenon and elevated SYNergy between PCI with TAXUS and Cardiac Surgery (SYNTAX-I) scores were higher in the group without SR than in the one with SR. Multivariate regression analysis indicated that a high PRECISE-DAPT score was an independent predictor of the absence of SR (odds ratio: 0.96, P = 0.04). The PRECISE-DAPT score is an independent predictor of the presence of spontaneous reperfusion in patients who experienced STEMI.

High bleeding risk in all-comers with ST-segment elevation myocardial infarction and use of P2Y12-inhibitiors

Abstract Background Bleeding has an important prognostic impact in patients with ST-segment elevation myocardial infarction (STEMI), yet stratification of bleeding risk to guide dual antiplatelet therapy (DAPT) is not routinely performed in clinical practice. Purpose To describe high bleeding risk (HBR) patients according to the PRECISE-DAPT (predicting bleeding complications in patients undergoing stent implantation and subsequent DAPT) score and use of P2Y12-inhibitors. Methods This single-centre observational study included consecutive patients with STEMI who were treated with percutaneous coronary intervention (PCI) from 2009–2016. Individual linkage to Danish nationwide registries was conducted to obtain information on diagnoses, claimed drugs, and vital status. Age, prior bleeding diagnosis, and blood samples before PCI (maximum 30 days before hospitalisation) were used to calculate the PRECISE-DAPT score. A score ≥25 was considered as HBR. Due to 26.7% missing on blood parameters (mainly leucocytes), the maximum and minimum values of the missing parameters and respective imputed PRECISE-DAPT scores were calculated. If both the maximum and minimum score were ≥25 or &amp;lt;25, patients were categorised accordingly, and a maximum score of ≥25 and minimum score of &amp;lt;25 as missing. Differences between continuous (median [interquartile range, IQR]) and categorical variables (frequency [percentage]) were assessed using Wilcoxon rank-sum and χ2-test for patients with vs. without HBR. Cumulative incidence of major bleeding (composite of bleedings leading to hospitalisation) and major adverse cardiovascular events (MACE) (composite of all-cause mortality, recurrent MI, and ischemic stroke) 1 year after PCI were plotted for patients with and without HBR. Number of HBR patients alive and collecting a P2Y12-inhibitor prescription within 30 days from discharge was reported. Results We identified 6179 PCI-treated patients with STEMI, of whom 5530 (89.5%) had imputed PRECISE-DAPT scores (Figure 1). A total of 1821 (32.9%) were at HBR, and these were more often female (38.3 vs. 18.2%, p-value&amp;lt;0.001), elderly (median age 75 [IQR 67, 81] vs. 57 years [IQR 51, 64], p-value&amp;lt;0.001), and had more comorbidities (diabetes [16.7 vs. 12.1%], heart failure [16.2 vs. 7.6%], cardiac arrhythmia [24.9 vs. 12.3%], cancer [17.5 vs. 5.7%], and ischemic stroke [8.1 vs. 2.6%], all p-values&amp;lt;0.001) compared with patients not at HBR. One-year cumulative incidence of major bleeding and MACE for patients with and without HBR were plotted (Figure 2). Of the 1431 (78.6%) HBR patients who were alive and claimed a P2Y12-inhibitior prescription 30 days from discharge, 459 (32.1%) were treated with clopidogrel, 672 (46.9%) with ticagrelor, and 300 (21.0%) with prasugrel (Figure 1). Conclusion Every third PCI-treated all-comer with STEMI was at HBR according to the PRECISE-DAPT score. HBR patients were more often treated with potent P2Y12-inhibitors (prasugrel or ticagrelor) instead of clopidogrel. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship.