How cardiologists can improve in-hospital outcomes after PCI
Two recently developed risk scores can identify bleeding risks among high-risk percutaneous coronary intervention (PCI) patients, according to new findings published in the American Journal of Cardiology.[1] These scores could potentially help cardiologists improve in-hospital outcomes and deliver better patient care.
The study’s authors focused their efforts on the predicting bleeding complications in patients who underwent stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score and Academic Research Consortium for High Bleeding Risk (ARC-HBR) score, hoping to gain a better understanding of their potential value to healthcare providers.
“Although the PRECISE-DAPT and ARC-HBR effectively predict bleeding after discharge, the clinical utility of these definitions alone or in combination for prediction of in-hospital outcomes, such as bleeding or ischemia, is unknown,” wrote first author Vishnu Kadiyala, MD, a specialist with the Warren Alpert Medical School of Brown University in Providence, Rhode Island, and colleagues. “We hypothesized that the two bleeding risk criteria, calculated before PCI, would be useful in assessing risk of in-hospital periprocedural bleeding and other adverse outcomes.”
Kadiyala et al. examined data from more than 3,500 patients who underwent PCI with a drug-eluting stent from January 2016 to March 2018 at one of two U.S. hospitals. Patients were excluded from this analysis in cases of out-of-hospital cardiac arrest, in-hospital coronary artery bypass graft (CABG) surgery or concomitant procedures such as transcatheter aortic valve replacement. The PRECISE-DAPT and ARC-HBR risk scores were retroactively calculated for each patient using data gathered before PCI was performed.
If patients had a PRECISE-DAPT score of 25 or higher—or met one major criterion and/or two minor criteria for ARC-HBR variables—they were categorized as facing a high bleeding risk. High-risk patients were more likely to be older, female and present with a history of previous myocardial infarction, previous PCI or previous CABG. They were also more likely to be a current smoker and present with peripheral artery disease, chronic lung disease or diabetes.
Post-PCI bleeding before hospital discharge was more likely to occur if the patient was older, female or present with a history of prior cardiovascular disease. These bleeding events were also more common when femoral access was used, an intra-aortic balloon pump (IABP) was used, or the patient was in cardiogenic shock, the authors added.
The research team also emphasized that women were consistently linked to a higher risk of post-PCI bleeding events before discharge.
“This is important because neither ARC-HBR nor PRECISE-DAPT includes gender to calculate the bleeding risk; thus, they may more appropriately account for variables driving increased bleeding risk in women,” the authors wrote.
At the end of the day, were the two risk scores effective bleeding risk in PCI?
The PRECISE-DAPT score found that 26.7% of patients faced an increased risk of a bleeding event, and the ARC-HBR score found that 37.7% of patients faced an increased risk. The actual percentage of patients who experienced a post-PCI bleeding event before hospital discharge was 3.3%—and, yes, that outcome was significantly more common among patients identified by either risk score. Secondary endpoints, including major adverse cardiovascular events and net adverse clinical events, were also more common among this patient population.
The risk scores were ultimately found to have “moderate predictive ability” for in-hospital bleeding events. The PRECISE-DAPT risk score had an area under the ROC curve (AUC) of 0.61, and the ARC-HBR risk score had an AUC of 0.62. Combining the two risk scores did not lead to a significant improvement in accuracy.
“This study suggests that the ARC-HBR and PRECISE-DAPT bleeding criteria can be used to risk stratify patients and guide the therapeutic selection to lower the bleeding risk,” the authors concluded. “For instance, we found that radial access was used at lower rates in patients stratified as having a higher bleeding risk, despite the lower rates of bleeding seen with radial access. Other strategies to lower bleeding risk include the choice of less potent P2Y12 inhibitors or minimizing use of upstream P2Y12 inhibitor in patients without STEMI and the choice of intraprocedural anticoagulation. A combination of these strategies may help lower the risk of bleeding among high-risk patients who underwent PCI.”
Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.