Does anemia affect the predictive ability of bleeding risk scores in patients with acute coronary syndromes?

Acute coronary syndromes (ACS) are a global leading cause of death. These syndromes show heterogeneity in presentation, mechanisms, outcomes and responses to treatment. Precision medicine aims to identify and synthesize unique features in individuals, translating the acquired data into improved personalised interventions. Current precision treatments of ACS include immediate coronary revascularisation driven by ECG ST-segment elevation, early coronary angiography based on elevated blood cardiac troponins in patients without ST-segment elevation, and duration of intensified antithrombotic therapy according to bleeding risk scores. Phenotypically stratified analyses of multi-omic datasets are urgently needed to further refine and couple the diagnosis and treatment of these potentially life-threatening conditions. We provide definitions, examples and possible ways to advance precision treatments of ACS.

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Long-Term Bleeding Risk Prediction with Dual Antiplatelet Therapy After Acute Coronary Syndromes Treated Without Revascularization

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.120.006582 ◽

2020 ◽

Vol 13 (9) ◽

Author(s):

Guillaume Marquis-Gravel ◽

Megan L. Neely ◽

Marco Valgimigli ◽

Francesco Costa ◽

David Van Klaveren ◽

...

Keyword(s):

Acute Coronary Syndromes ◽

Dual Antiplatelet Therapy ◽

Artery Bypass ◽

Bleeding Risk ◽

Coronary Intervention ◽

Risk Scores ◽

Percutaneous Coronary ◽

Life Threatening ◽

Coronary Syndromes ◽

Component Scores

Background: Longitudinal bleeding risk scores have been validated in patients treated with dual antiplatelet therapy (DAPT) following percutaneous coronary intervention. How these scores apply to the population of patients with acute coronary syndrome (ACS) treated without revascularization remains unknown. The objective was to evaluate and compare the performances of the PRECISE-DAPT, PARIS, and DAPT (bleeding component) bleeding risk scores in the medically managed patients with ACS treated with DAPT. Methods and Results: TRILOGY ACS (Targeted Platelet Inhibition to Clarify the Optimal Strategy to Medically Manage Acute Coronary Syndromes) was a double-blind, placebo-controlled randomized trial conducted from 2008 to 2012 over a median follow-up of 17.0 months in 966 sites (52 countries). High-risk patients with unstable angina or non–ST-segment–elevation myocardial infarction who did not undergo revascularization were randomized to prasugrel or clopidogrel. The PRECISE-DAPT, PARIS, and DAPT (bleeding component) risk scores were applied in the TRILOGY ACS population to evaluate their performance to predict adjudicated non–coronary artery bypass grafting–related GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries) severe/life-threatening/moderate and TIMI (Thrombolysis in Myocardial Infarction) major/minor bleeding with time-dependent c-indices. Among the 9326 participants, median age was 66 years (interquartile range, 59–74 years), and 3650 were females (39.1%). A total of 158 (1.69%) GUSTO severe/life-threatening/moderate and 174 (1.87%) TIMI major/minor non–coronary artery bypass grafting bleeding events occurred. The c-indices (95% CI) of the PRECISE-DAPT, PARIS, and DAPT (bleeding component) scores through 12 months were 0.716 (0.677–0.758), 0.693 (0.658–0.733), and 0.674 (0.637–0.713), respectively, for GUSTO bleeding and 0.624 (0.582–0.666), 0.612 (0.578–0.651), and 0.608 (0.571–0.649), respectively, for TIMI bleeding. There was no significant difference in the c-indices of each score based upon pairwise comparisons. Conclusions: Among medically managed patients with ACS treated with DAPT, the performances of the PRECISE-DAPT, PARIS, and DAPT (bleeding component) scores were reasonable and similar to their performances in the derivation percutaneous coronary intervention populations. Bleeding risk scores may be used to predict longitudinal bleeding risk in patients with ACS treated with DAPT without revascularization and help support shared decision making. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT00699998.

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Efficacy of bleeding risk scores in elderly Algerian patients with acute coronary syndromes

Archives of Cardiovascular Diseases Supplements ◽

10.1016/j.acvdsp.2019.09.030 ◽

2020 ◽

Vol 12 (1) ◽

pp. 17

Author(s):

H. Foudad ◽

I. Bouaguel ◽

A. Trichine

Keyword(s):

Acute Coronary Syndromes ◽

Bleeding Risk ◽

Risk Scores ◽

Coronary Syndromes

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Abstract 3581: Predicting Mortality in Acute Coronary Syndromes; A Comparison of the TIMI and GRACE Risk Scores

Circulation ◽

10.1161/circ.116.suppl_16.ii_810-c ◽

2007 ◽

Vol 116 (suppl_16) ◽

Author(s):

Krishna Aragam ◽

Umesh Tamhane ◽

Eva Kline-Rogers ◽

Jin Li ◽

Keith A Fox ◽

...

Keyword(s):

Acute Coronary Syndromes ◽

Predictive Ability ◽

Risk Scores ◽

Admission Diagnosis ◽

Post Discharge ◽

Timi Score ◽

Coronary Syndromes ◽

Coronary Events ◽

Grace Score ◽

Better Than

Background: The Thrombolysis In Myocardial Infarction (TIMI) and the Global Registry of Acute Coronary Events (GRACE) risk scores are widely recognized tools for assessing risk in patients with acute coronary syndromes (ACS). However, their relative predictive abilities remain poorly defined in broad-spectrum ACS populations. Objective: We sought to compare the effectiveness of the GRACE and TIMI risk scores in predicting in-hospital and 6-month post-discharge mortality in unselected patients presenting with ACS. Methods: Data were collected for 3451 patients admitted to the University of Michigan between 1999 and 2005 with an admission diagnosis of ACS. Six month follow-up data were available for 3170 of these patients. GRACE and TIMI scores were calculated for each patient based on previously established criteria. The predictive ability of each score was assessed for two primary outcomes - in-hospital mortality and 6-month mortality - by analyzing the area under each receiver operating characteristic (ROC) curve. Results: The observed mortality was 3.97% (137 deaths) in-hospital and 7.38% (234 deaths) at 6 months among those surviving to hospital discharge. The GRACE score was significantly better than the TIMI score in predicting in hospital and 6-month mortality (p<0.0001 in both cases, Figure ). Conclusion: The GRACE score was significantly better than the TIMI score in predicting in-hospital and 6-month mortality in unselected patients presenting with ACS.

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Efficacy of Bleeding Risk Scores in Elderly Patients with Acute Coronary Syndromes

Revista Española de Cardiología (English Edition) ◽

10.1016/j.rec.2013.10.008 ◽

2014 ◽

Vol 67 (6) ◽

pp. 463-470 ◽

Cited By ~ 2

Author(s):

Albert Ariza-Solé ◽

Francesc Formiga ◽

Victoria Lorente ◽

José C. Sánchez-Salado ◽

Guillermo Sánchez-Elvira ◽

...

Keyword(s):

Elderly Patients ◽

Acute Coronary Syndromes ◽

Bleeding Risk ◽

Risk Scores ◽

Coronary Syndromes

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Prediction of Post-Discharge Bleeding in Elderly Patients with Acute Coronary Syndromes: Insights from the BleeMACS Registry

Thrombosis and Haemostasis ◽

10.1055/s-0038-1635259 ◽

2018 ◽

Vol 118 (05) ◽

pp. 929-938 ◽

Cited By ~ 4

Author(s):

Alberto Garay ◽

Francesc Formiga ◽

Sergio Raposeiras-Roubín ◽

Emad Abu-Assi ◽

José Sánchez-Salado ◽

...

Keyword(s):

Elderly Patients ◽

Acute Coronary Syndromes ◽

Predictive Ability ◽

Roc Curves ◽

Risk Scores ◽

Bleeding Complications ◽

Severe Bleeding ◽

Post Discharge ◽

Coronary Syndrome ◽

Coronary Syndromes

Background A poor ability of recommended risk scores for predicting in-hospital bleeding has been reported in elderly patients with acute coronary syndromes (ACS). No study assessed the prediction of post-discharge bleeding in the elderly. The new BleeMACS score (Bleeding complications in a Multicenter registry of patients discharged with diagnosis of Acute Coronary Syndrome), was designed to predict post-discharge bleeding in ACS patients. We aimed to assess the predictive ability of the BleeMACS score in elderly patients. Methods We assessed the incidence and characteristics of severe bleeding after discharge in ACS patients aged ≥ 75 years. Bleeding was defined as any intracranial bleeding or bleeding leading to hospitalization and/or red blood transfusion, occurring within the first year after discharge. We assessed the predictive ability of the BleeMACS score according to age by Fine–Gray proportional hazards regression analysis, calculating receiver-operating characteristic (ROC) curves and the area under the ROC curves (AUC). Results The BleeMACS registry included 15,401 patients of whom 3,376/15,401 (21.9%) were aged ≥ 75 years. Elderly patients were more commonly treated with clopidogrel and less often treated with ticagrelor or prasugrel. Of 3,376 elderly patients, 190 (5.6%) experienced post-discharge bleeding. The incidence of bleeding was moderately higher in elderly patients (hazard ratio [HR], 2.31, 95% confidence interval [CI], 1.92–2.77). The predictive ability of the BleeMACS score was moderately lower in elderly patients (AUC, 0.652 vs. 0.691, p = 0.001). Conclusion Elderly patients with ACS had a significantly higher incidence of post-discharge bleeding. Despite a lower predictive ability in older patients, the BleeMACS score exhibited an acceptable performance in these patients.

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Comparison of CRUSADE and ACUITY-HORIZONS Bleeding Risk Scores in Patients With Acute Coronary Syndromes

Heart Lung and Circulation ◽

10.1016/j.hlc.2018.02.012 ◽

2019 ◽

Vol 28 (4) ◽

pp. 567-574 ◽

Cited By ~ 1

Author(s):

Diego Castini ◽

Marco Centola ◽

Giulia Ferrante ◽

Sara Cazzaniga ◽

Simone Persampieri ◽

...

Keyword(s):

Acute Coronary Syndromes ◽

Bleeding Risk ◽

Risk Scores ◽

Coronary Syndromes

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Is there Sex-related Outcome Difference According to oral P2Y12 Inhibitors in Patients with Acute Coronary Syndromes? A Systematic Review and Meta-Analysis of 107,126 Patients

Current Vascular Pharmacology ◽

10.2174/1570161116666180123092054 ◽

2019 ◽

Vol 17 (2) ◽

pp. 191-203

Author(s):

Oliver Brown ◽

Jennifer Rossington ◽

Gill Louise Buchanan ◽

Giuseppe Patti ◽

Angela Hoye

Keyword(s):

Systematic Review ◽

Acute Coronary Syndromes ◽

Meta Analysis ◽

Indirect Comparison ◽

Bleeding Risk ◽

Cardiovascular Death ◽

P2y12 Inhibitors ◽

Significant Difference ◽

Coronary Syndromes ◽

Randomised Controlled

Background and Objectives: The majority of patients included in trials of anti-platelet therapy are male. This systematic review and meta-analysis aimed to determine whether, in addition to aspirin, P2Y12 blockade is beneficial in both women and men with acute coronary syndromes. Methods: Electronic databases were searched and nine eligible randomised controlled studies were identified that had sex-specific clinical outcomes (n=107,126 patients). Risk Ratios (RR) and 95% Confidence Intervals (CI) were calculated for a composite of cardiovascular death, myocardial infarction or stroke (MACE), and a safety endpoint of major bleeding for each sex. Indirect comparison analysis was performed to statistically compare ticagrelor against prasugrel. Results: Compared to aspirin alone, clopidogrel reduced MACE in men (RR, 0.79; 95% CI, 0.68 to 0.92; p=0.003), but was not statistically significant in women (RR, 0.88; 95% CI, 0.75 to 1.02, p=0.08). Clopidogrel therapy significantly increased bleeding in women but not men. Compared to clopidogrel, prasugrel was beneficial in men (RR, 0.84; 95% CI, 0.73 to 0.97; p=0.02) but not statistically significant in women (RR, 0.94; 95% CI, 0.83 to 1.06; p=0.30); ticagrelor reduced MACE in both men (RR, 0.85; 95% CI, 0.77 to 0.94; p=0.001) and women (RR, 0.84; 95% CI, 0.73 to 0.97; p=0.02). Indirect comparison demonstrated no significant difference between ticagrelor and prasugrel in either sex. Compared to clopidogrel, ticagrelor and prasugrel increased bleeding risk in both women and men. Conclusion: In summary, in comparison to monotherapy with aspirin, P2Y12 inhibitors reduce MACE in women and men. Ticagrelor was shown to be superior to clopidogrel in both sexes. Prasugrel showed a statistically significant benefit only in men; however indirect comparison did not demonstrate superiority of ticagrelor over prasugrel in women.

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