A Risk Score to Predict Post-Discharge Bleeding Among Acute Coronary Syndrome Patients Undergoing Percutaneous Coronary Intervention: BRIC-ACS Study

Yang, Junjie

Background
Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) prevents ischemic events while increasing bleeding risk. Real-world based metrics to accurately predict post-discharge bleeding (PDB) occurrence and its potential impact on post-discharge 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
From May 2014 to January 2016, 2496 ACS patients who underwent PCI were recruited consecutively from 29 nationally representative Chinese tertiary hospitals. The association between PDB (Bleeding Academic Research Consortium type [BARC]≥2) and MACE (a composite of all-cause death, non-fatal myocardial infarction, ischemic stroke, or urgent revascularization) during 1-year follow-up, as well as the impact of DAPT with ticagrelor or clopidogrel on PDB were evaluated. Based on identified PDB predictors, a risk score for PDB was established and validated.

Results
Among 2381 patients (95.4%, 2381/2496) who completed 1-year follow-up, the cumulative incidence of PDB and post-discharge MACE was 4.9% (n=117) and 3.3% (n= 79), respectively. PDB was associated with higher risk of post-discharge MACE (7.7% vs. 3.1%; adjusted hazard ratio: 2.59 [95% confidence interval: 1.17 to 5.74]; P=0.02). For ticagrelor vs. clopidogrel, PDB risk was higher (8.0% vs. 4.4%; 2.05 [1.17-3.60]; P=0.01), while MACE risk was similar (2.0% vs. 3.4%; 0.70 [0.25-1.93]; P=0.49). C-statistic for the constructed BRIC-ACS 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. This study was sponsored by Sanofi. The authors are responsible for all content and received no payment from Sanofi directly or indirectly related to the development of publication.