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Validation of High-Risk Features for Stent-Related Ischemic Events
Study Questions:
What is the validity of the European Society of Cardiology (ESC) dual antiplatelet therapy (DAPT) guideline-endorsed high-risk features of stent-related recurrent ischemic events for the prediction of ischemic and bleeding outcomes, including a stratification according to the PRECISE-DAPT score estimated bleeding risk?
Methods:
The investigators included 10,236 consecutive patients undergoing clinically indicated percutaneous coronary intervention (PCI) between February 2009 and December 2015 in the Bern PCI Registry. Guideline-endorsed high-risk features were retrospectively assessed. The primary ischemic endpoint was device-oriented composite endpoint (DOCE), which included cardiac death, target vessel myocardial infarction, and target lesion revascularization at 1 year, and the primary bleeding endpoint was Bleeding Academic Research Consortium (BARC) 3-5 at 1 year. Cox regression analysis was performed to build a separate multivariate model to calculate individual predicted probabilities for DOCE and BARC 3-5, and to test the prognostic significance of high-risk features and each component for study endpoints.
Results:
A total of 5,323 (52.0%) patients had at least one high-risk feature. Among patients with high-risk features, DOCE (12.3% vs. 5.5%, p < 0.001) and BARC 3-5 bleeding (4.9% vs. 2.2%, p < 0.001) occurred more frequently compared with those without. There was a graded risk increase for DOCE (0: 5.5%, 1-2: 11.3%, and ≥3: 16.7%; p < 0.001) and BARC 3-5 bleeding (0: 2.2%, 1-2: 4.5%, and ≥3: 6.6%; p < 0.001) as the number of high-risk features increased. High-PRECISE-DAPT score (≥25) was associated with an increased risk of DOCE and BARC 3-5 bleeding, irrespective of number of high-risk features.
Conclusions:
The authors concluded that the ESC guideline-endorsed high-risk features were associated with both increased ischemic and bleeding risks following PCI in routine clinical practice.
Perspective:
This study reports that patients with guideline-endorsed high-risk features had a higher risk of ischemic (DOCE) and bleeding (BARC 3-5) events. Furthermore, those with high-risk bleeding criteria (i.e., PRECISE-DAPT score ≥25) carried a higher risk of DOCE and bleeding BARC 3-5, irrespective of the number of high-risk features present. Individual high-risk features such as number of stents or lesions, which are independent predictors for ischemic events but not for bleeding, may be useful to guide prolonged DAPT use or use of potent P2Y12, whereas others such as chronic kidney disease, which is an independent predictor of both DOCE and BARC 3-5, may be less helpful. Additional studies are indicated to optimize intensity and duration of DAPT among the challenging patients with both an increased bleeding and ischemic risk.
Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Prevention, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and ACS, Interventions and Coronary Artery Disease
Keywords: Acute Coronary Syndrome, Coronary Artery Disease, Hemorrhage, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Risk Factors, Secondary Prevention, Stents
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