A risk score to predict postdischarge bleeding among acute coronary syndrome patients undergoing percutaneous coronary intervention: BRIC‐ACS study

Abstract

Background Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) prevents ischemic events while increasing bleeding risk. Real‐world‐based metrics to accurately predict postdischarge bleeding (PDB) occurrence and its potential impact on postdischarge major cardiovascular event (MACE) remain undefined. This study sought to evaluate the impact of PDB on MACE occurrence, and to develop a score to predict PDB risk among Chinese acute coronary syndrome (ACS) patients after PCI. Methods and Results From May 2014 to January 2016, 2496 ACS patients who underwent PCI were recruited consecutively from 29 nationally representative Chinese tertiary hospitals. Among 2,381 patients (95.4%, 2,381/2,496) who completed 1‐year follow‐up, the cumulative incidence of PDB (bleeding academic research consortium type [BARC] ≥2) and postdischarge MACE (a composite of all‐cause death, nonfatal myocardial infarction, ischemic stroke, or urgent revascularization) was 4.9% (n = 117) and 3.3% (n = 79), respectively. The association between PDB and MACE during 1‐year follow‐up, as well as the impact of DAPT with ticagrelor or clopidogrel on PDB were evaluated. PDB was associated with higher risk of postdischarge MACE (7.7 vs. 3.1%; adjusted hazard ratio: 2.59 [95% confidence interval: 1.17–5.74]; p = .02). For ticagrelor versus clopidogrel, PDB risk was higher (8.0 vs. 4.4%; 2.05 [1.17–3.60]; p = .01), while MACE risk was similar (2.0 vs. 3.4%; 0.70 [0.25–1.93]; p = .49). Based on identified PDB predictors, the constructed bleeding risk in real world Chinese acute coronary syndrome patients (BRIC‐ACS) score for PDB was established. C‐statistic for the score for PDB was 0.67 (95% CI: 0.62–0.73) in the overall cohort, and >0.70 in subgroups with non‐ST‐ and ST‐segment elevation myocardial infarction, diabetes and receiving more than two drug eluting stents. Conclusions In Chinese ACS patients, PDB with BARC ≥2 was associated with higher risk for MACE after PCI. The constructed BRIC‐ACS risk score provides a useful tool for PDB discrimination, particularly among high ischemic and bleeding risk patients.

Incidence and predictors of serious bleeding during long-term follow-up after acute coronary syndrome in a population-based cohort study

“…Consistent with other studies, the gut 15 , 21 , 28 was the most frequent identifiable source of bleeding in our study. It was also the most common location for a second bleeding event, regardless of the location of the first site.…”

Predictors and long‐term outcomes of in‐hospital switching from clopidogrel to ticagrelor among patients with acute coronary syndrome undergoing percutaneous coronary intervention

“…Consistent with the findings of previous studies, 32,33 gastrointestinal hemorrhage was the most common type of clinically relevant bleeding in our study. Furthermore, it occurred more frequently in patients switched to ticagrelor than in those continued on clopidogrel.…”

“…Our study shares similar results with another real-world observational research, the BRIC-ACS study, 33 in which ticagrelor was strongly associated with a higher risk of BARC Type 2/3/5 bleeding but not with a lower risk of MACE in comparison to clopidogrel.…”

Factors predicting the occurrence of net adverse clinical and cerebral events in patients with acute coronary syndrome treated with clopidogrel or ticagrelor in combination with aspirin: a real-world study

“…The database included 31 centers with 7,862 Chinese adult ACS patients who underwent PCI, and these patients were discharged from hospital between January 2014 and October 2017. Patient data were obtained from the BRIC-ACS(I) study (2,381 patients) (6), COSTIC study (4,447 patients) (10), and cases from the Sixth Medical Center of PLA General Hospital PCI patient database (1,034 patients). The data for the patients who underwent PCI with second-or thirdgeneration drug-eluting stent (DES) implantation, and were treated either with clopidogrel or ticagrelor plus aspirin for 12 months of follow-up were included in this real-world study.…”

“…However, the pharmacological limitations associated with clopidogrel DAPT have led to the development of novel reversible P2Y12 receptor antagonists (5). According to the current guidelines based on previously conducted clinical trials [PLATO trial (3)], the use of ticagrelor as a novel potent P2Y12 inhibitor is recommended after PCI for 12 months to reduce coronary thrombosis and mortality in patients with ACS (6). Studies have shown that DAPT reduces the risk of stent-related and spontaneous recurrent ischemic events in patients with ACS undergoing PCI.…”