A Systematic Review on Bleeding Risk Scores' Accuracy after Percutaneous Coronary Interventions in Acute and Elective Settings

LASSO-derived model for the prediction of bleeding in aspirin users

Aspirin is widely used for both primary and secondary prevention of panvascular diseases, such as stroke and coronary heart disease (CHD). The optimal balance between reducing panvascular disease events and the potential increase in bleeding risk remains unclear. This study aimed to develop a predictive model specifically designed to assess bleeding risk in individuals using aspirin. A total of 58,415 individuals treated with aspirin were included in this study. Detailed data regarding patient demographics, clinical characteristics, comorbidities, medical history, and laboratory test results were collected from the Affiliated Dongyang Hospital of Wenzhou Medical University. The patients were randomly divided into two groups at a ratio of 7:3. The larger group was used for model development, while the smaller group was used for internal validation. To develop the prediction model, we employed least absolute shrinkage and selection operator (LASSO) regression followed by multivariate logistic regression. The performance of the model was assessed through metrics such as the area under the receiver operating characteristic (ROC) curve (AUC), calibration curves, and decision curve analysis (DCA). The LASSO-derived model employed in this study incorporated six variables, namely, sex, operation, previous bleeding, hemoglobin, platelet count, and cerebral infarction. It demonstrated excellent performance at predicting bleeding risk among aspirin users, with a high AUC of 0.866 (95% CI 0.857-0.874) in the training dataset and 0.861 (95% CI 0.848-0.875) in the test dataset. At a cutoff value of 0.047, the model achieved moderate sensitivity (83.0%) and specificity (73.9%). The calibration curve analysis revealed that the nomogram closely approximated the ideal curve, indicating good calibration. The DCA curve demonstrated a favorable clinical net benefit associated with the nomogram model. Our developed LASSO-derived predictive model has potential as an alternative tool for predicting bleeding in clinical settings.

Performance of the Academic Research Consortium High Bleeding Risk Criteria in Patients With ST-Segment Elevation Myocardial Infarction: A Single Center Study

We assessed the ability of predicting mortality and total in-hospital bleeding and adverse outcomes by the Academic Research Consortium High Bleeding Risk (ARC-HBR) criteria in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (pPCI). A total of 1441 STEMI patients were recruited: HBR group 354 (25%) patients and non-HBR group of 1087 (75%) patients. A total of 131 patients (9%) had a bleeding complication during hospitalization. The bleeding complications were also categorized according to other conventional bleeding scores. According to these conventional scores, all bleeding categories were associated with HBR. In univariate logistic regression analysis, female gender, diabetes mellitus, hypertension (HT) and HBR were associated with in-hospital bleeding. However, in multivariable analysis only HT (Odds Ratio [OR] 1.528, 95% CI 1.020-2.290; P = .040) and HBR (OR 1.612, 95% CI 1.075-2.428; P = .022) independently predicted total in-hospital bleeding complications. Hospital duration was longer and mortality rate was significantly higher in patients with HBR (OR 8.755, 95% CI 5.864-13.074; P < .01). The ARC-HBR criteria may predict in-hospital bleeding events and adverse outcomes in STEMI patients undergoing pPCI.

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

AIMS

To summarize 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.

METHODS AND RESULTS

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 ratios (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 21 studies and 67 283 patients were included; 24.7% of patients (N = 16 603) were at high bleeding risk (PRECISE-DAPT score ≥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).

CONCLUSION

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.

Walking the Line with Ticagrelor: Meta-Analysis Comparing the Safety and Efficacy of Ticagrelor Monotherapy after a Short Course of Ticagrelor-Based Dual Antiplatelet Therapy versus Standard Therapy in Complex Percutaneous Coronary Intervention

(1) Shorter-duration dual antiplatelet therapy (DAPT) followed by single antiplatelet therapy has been shown to significantly reduce bleeding events while preserving anti-ischemic effects in patients undergoing conventional percutaneous coronary interventions (PCI). Whether this strategy is also safe and effective in complex PCI remains elusive; (2) A systematic search of randomized controlled trials comparing a short course of ticagrelor-based DAPT versus standard DAPT in patients undergoing complex PCI was performed; (3) Of 10,689 studies screened, 3 were identified for a total of 4176 participants on ticagrelor monotherapy after a short course of ticagrelor-based DAPT, and 4209 on standard DAPT. The pooled analysis revealed no difference in the outcomes of major bleeding, myocardial infarction, definite or probable stent thrombosis and ischemic stroke. A significant reduction in the risk of cardiovascular death (incidence rate ratio (IRR) 0.52; 95% CI 0.28–0.96; p = 0.04), all-cause death (IRR 0.65; 95% CI 0.49–0.86; p = 0.003), and any bleeding events (IRR 0.62; 95% CI 0.47–0.81; p < 0.001) was seen in the shorter DAPT group; (4) Among patients undergoing complex PCI, ticagrelor monotherapy after a short course of ticagrelor-based DAPT significantly reduced bleeding risk without increasing ischemic risk. More data are needed to definitively explain mortality benefits.