Impact of clinical presentation on bleeding risk after percutaneous coronary intervention and implications for the ARC-HBR definition

Gragnano, Felice; Spirito, Alessandro; Corpataux, Noé; Vaisnora, Lukas; Galea, Roberto; Gargiulo, Giuseppe; Siontis, George C.M.; Praz, Fabien; Lanz, Jonas; Billinger, Michael; Hunziker, Lukas; Stortecky, Stefan; Pilgrim, Thomas; Bär, Sarah; Ueki, Yasushi; Capodanno, Davide; Urban, Philip; Pocock, Stuart J.; Mehran, Roxana; Heg, Dik; Windecker, Stephan; Räber, Lorenz; Valgimigli, Marco

doi:10.4244/eij-d-21-00181

Cited by 53 publications

(43 citation statements)

References 21 publications

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“…NSAIDs or steroids were moderately prevalent. Previous studies have reported similar results [ 14 , 19 , 20 , 21 , 22 , 23 , 24 ]. OAC-use and age seem to be even more prevalent in Finnish patients, but active malignancy is less frequently encountered.…”

Section: Discussionsupporting

confidence: 80%

“…The prevalence of HBR according to ARC–HBR criteria in studies of European and Asian populations has ranged from 30% to 50%, and the incidence of major bleeding events in the HBR groups of these studies has consistently been ≥4% at 1 year [ 14 , 19 , 20 , 21 , 22 , 23 , 24 ]. The highest major bleeding rates were reported in Korea.…”

Section: Discussionmentioning

confidence: 99%

“…Thus, the choice of treatment should be decided upon based on both the ischemic risk and the bleeding risk of the individual patient [ 11 , 12 , 13 ]. A recent study demonstrated that the clinical presentation of ACS per se predicts increased bleeding risk, as compared to chronic coronary syndrome, further emphasizing the importance of considering these two aspects during decision making [ 14 ].…”

Section: Introductionmentioning

confidence: 99%

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Prevalence of High Bleeding Risk among Hospitalized Suspected NSTEMI Patients

Kesti

Mäkinen

Mattila

et al. 2022

JCM

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In recent years, guidelines for the management of acute coronary syndromes (ACS) have placed more emphasis on identifying patients at high bleeding risk (HBR). We set out to investigate the prevalence of HBR patients according to the Academic Research Consortium for High Bleeding Risk (ARC–HBR) criteria in hospitalized patients with suspected non-ST-segment elevation myocardial infarction (NSTEMI). Consecutive patients were retrospectively enrolled between January and June 2019 from the emergency department (ED) of a tertiary hospital. The discharge diagnosis and baseline data were manually collected using electronic patient records and database searches. Patients with non-cardiac diagnoses were excluded. Overall, 212 patients were included in the study. A total of 146 (68.9%) patients were diagnosed with NSTEMI (Type 1), 47 (22.2%) with unstable angina pectoris (UAP) and 19 (9.0%) with “other.” HBR was detected in 47.6% (n = 101) of all patients. Common criteria for HBR among ACS patients were age (40.4%), chronic kidney disease (33.7%), and the use of oral anticoagulation medicines (20.2%). In conclusion, nearly half of the patients hospitalized for ACS fulfilled HBR criteria. According to contemporary guidelines, the management of HBR patients differs from that of non-HBR patients, and thus, a more comprehensive screening for HBR may be considered in clinical practice.

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Section: Discussionsupporting

confidence: 80%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Prevalence of High Bleeding Risk among Hospitalized Suspected NSTEMI Patients

Kesti

Mäkinen

Mattila

et al. 2022

JCM

View full text Add to dashboard Cite

show abstract

“…The medications used in the follow-up included aspirin, clopidogrel, atorvastatin calcium, metoprolol tartrate and diltiazem. ACS remained to be associated with higher BARC 3 or 5 bleeding risk, and then the patient received Pantoprazole after operation [ 7 ]. He was followed up for 12 months, and showed a normal status with no cerebrovascular events.…”

Section: Resultsmentioning

confidence: 99%

Perioperative coronary artery spasm after off-pump coronary artery bypass grafting in the non-manipulated coronary artery

Bai

Jiang

et al. 2022

BMC Cardiovasc Disord

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Background Perioperative coronary artery spasm (CAS) following coronary artery bypass grafting (CABG) is a severe or lethal condition that is rarely reported. In addition, rare cases with CAS following CABG in the non-manipulated coronary artery are angiographically documented in the perioperative period. We aimed to report our experiences on the diagnosis and treatment of a case with CAS following off-pump CABG in the non-manipulated coronary artery. Methods A 57-year old male with coronary heart disease and unstable angina willing to undergo CABG was admitted to our department. CABG was recommended as he showed 90% stenosis in distal left anterior descending artery, 90% stenosis in intermediate branch, 90% stenosis in left circumflex coronary artery, as well as 50% stenosis in proximal right coronary artery (RCA). Results After CABG, the patient showed Adams–Stokes syndrome and ST-segment elevation. Then CPR was conducted and coronary angiography indicated perioperative CAS in the non-manipulated posterior descending artery. For the treatment, the patient received nitroglycerin injection into the coronary artery by catheter and pumping of diltiazem. Finally, the patient was discharged on day 7 after surgery. A comprehensive literature search was conducted to summarize the studies focused on the diagnosis and treatment of such condition, which indicated that all of the CAS cases occurred in the manipulated vessels, except one study showing CAS in the untouched native coronary artery which was similar with our case. Conclusions Perioperative CAS in the non-manipulated coronary artery following CABG is a severe or lethal condition that is rarely reported, which deserves close attention by the clinicians in clinical practice.

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“…Recently, the ARC-HBR criteria were established to standardize the definition of HBR and promote consistency across trials evaluating this vulnerable subset of patients [ 31 ]. A number of studies have reported on the predictive value of the ARC-HBR definition in identifying patients at increased risk not only for bleeding but also for thrombotic events [ 18 , 32 – 34 ], as well as validated the clinical usefulness of the ARC-HBR criteria in relation to clinical presentation and sex [ 35 , 36 ]. Given that bleeding risk was a major reason for discontinuation of DAPT, we also assessed the effects of DAPT interruption ≤12 months compared with DAPT maintenance >12 months in a contemporary PCI population at high ischemic risk and HBR ( Table 4 ).…”

Section: Discussionmentioning

confidence: 99%

Thrombotic vs. Bleeding Events of Interruption of Dual Antiplatelet Therapy within 12 Months among Patients with Stent-Driven High Ischemic Risk Definition following PCI

Wang

Song

et al. 2022

Journal of Interventional Cardiology

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Background. There is a paucity of real-world data regarding the clinical impact of dual antiplatelet therapy (DAPT) interruption (temporary or permanent) among patients at high ischemic risk. The aim of this study was to assess the risk of cardiovascular events after interruption of DAPT in high-risk PCI population. Methods. This study used data from the Fuwai PCI registry, a large, prospective cohort of consecutive patients who underwent PCI. We assessed 3,931 patients with at least 1 high ischemic risk criteria of stent-related recurrent ischemic events proposed in the 2017 ESC guidelines for focused update on DAPT who were free of major cardiac events in the first 12 months. The primary ischemic endpoint was 30-month major adverse cardiac and cerebrovascular events, and the key safety endpoints were BARC class 2, 3, or 5 bleeding and net adverse clinical events. Results. DAPT interruption within 12 months occurred in 1,122 patients (28.5%), most of which were due to bleeding events or patients’ noncompliance to treatment. A multivariate Cox regression model, propensity score (PS) matching, and inverse probability of treatment weighting (IPTW) based on the propensity score demonstrated that DAPT interruption significantly increased the risk of primary ischemic endpoint compared with prolonged DAPT (3.9% vs. 2.2%; Cox-adjusted hazard ratio (HR): 1.840; 95% confidence interval (CI): 1.247 to 2.716; PS matching-HR: 2.049 [1.236–3.399]; IPTW-adjusted HR: 1.843 [1.250–2.717]). This difference was driven mainly by all-cause death (1.8% vs. 0.7%) and MI (1.3% vs. 0.5%). Furthermore, the rate of net adverse clinical events (4.9% vs. 3.2%; Cox-adjusted HR: 1.581 [1.128–2.216]; PS matching-HR: 1.639 [1.075–2.499]; IPTW-adjusted HR: 1.554 [1.110–2.177]) was also higher in patients with DAPT interruption (≤12 months), whereas no significant differences between groups were observed in terms of BARC 2, 3, or 5 bleeding. These findings were consistent across various stent-driven high-ischemic risk subsets with respect to the primary ischemic endpoints, with a greater magnitude of harm among patients with diffuse multivessel diabetic coronary artery disease. Conclusions. In patients undergoing high-risk PCI, interruption of DAPT in the first 12 months occurred infrequently and was associated with a significantly higher adjusted risk of major adverse cardiovascular events and net adverse clinical events. 2017 ESC stent-driven high ischemic risk criteria may help clinicians to discriminate patient selection in the use of long-term DAPT when the ischemic risk certainly overcomes the bleeding one.

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Impact of clinical presentation on bleeding risk after percutaneous coronary intervention and implications for the ARC-HBR definition

Cited by 53 publications

References 21 publications

Prevalence of High Bleeding Risk among Hospitalized Suspected NSTEMI Patients

Prevalence of High Bleeding Risk among Hospitalized Suspected NSTEMI Patients

Perioperative coronary artery spasm after off-pump coronary artery bypass grafting in the non-manipulated coronary artery

Thrombotic vs. Bleeding Events of Interruption of Dual Antiplatelet Therapy within 12 Months among Patients with Stent-Driven High Ischemic Risk Definition following PCI

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