Thrombotic Risk Criteria Post-PCI for NSTE ACS Validated in New Analysis

PHOENIX, AZ—Thrombotic risk criteria proposed in the recently updated European guidelines for non-ST-segment elevation acute coronary syndromes (NSTE ACS) are accurate in identifying patients at increased risk for post-PCI events, a real-world analysis suggests.

“We aimed the current analysis to assess the value of this [set of] criteria to identify patients at high risk for ischemic events in our own hospitals’ database,” said George Dangas, MD, PhD (Icahn School of Medicine at Mount Sinai, New York, NY), in his presentation here at the Society for Cardiovascular Angiography and Interventions (SCAI) 2023 Scientific Sessions.

The cohort consisted of 11,787 consecutive patients with acute or chronic coronary syndrome who underwent PCI between 2012 and 2019.

When classified according to the 2020 European Society of Cardiology (ESC) guidelines as either low-, moderate- or high-thrombotic risk (22%, 45%, and 33% of patients, respectively), there was a clear incremental risk of the cumulative incidence of all-cause death, MI, or stroke at 1 year from low to moderate to high risk (1.6% vs 4.1% vs 5.4%; P < 0.001).

“Importantly, this was accompanied by a gradation in the risk of all-cause mortality at 1 year from 0.6% in the low-risk, all the way up incrementally to 2.7% in the high-risk group,” Dangas added. These differences also were statistically significant, with a log-rank P of < 0.001, suggesting that patients with moderate or high risk should be evaluated for more-intensive anti-ischemic therapies.

Bleeding risk was similarly affected by risk categorization, with 1-year risks of major bleeding being 3.8% in the low-risk group, 4.6% in the moderate-risk group, and 5.9% in the high-risk group.

Moderate-risk patients had one or more clinical features, including diabetes, prior MI, PAD, or chronic kidney disease, defined as an eGFR < 60 mL/min/1.73 m2. High-risk patients had one or more of those same clinical features plus one or more angiographic or procedural features such as younger age, multivessel CAD, or total stent length > 60 mm. Low-risk patients had none of these features.

Calibration and Characteristics

In a concordance analysis, the ESC criteria were predictive of death, MI, or stroke in this cohort, with a C-statistic of 0.60, or 60%, which indicates moderate predictive ability for that outcome as well as all-cause death, Dangas said. The predictive ability was less than 60% for the other individual outcomes.

The analysis has some limitations, including the fact that the follow-up was limited to 1 year after PCI and some less-frequent ESC thrombotic risk criteria were not captured by the database, including  accelerated CAD, systemic inflammatory disease, and a history of stent thrombosis on dual antiplatelet therapy (DAPT). There also were no data on DAPT duration or adherence over time, and causes of death were not available.

“Future studies should confirm the value of these criteria to identify patients deriving a net benefit from an extended treatment with a second antithrombotic agent,” Dangas concluded.

To TCTMD, he said future research might focus on incorporating additional patient-specific characteristics such as sex, race, and ethnicity.

“I think we may consider those in further calibration that we do,” he said, adding that for the purposes of this analysis the researchers utilized the predictive criteria exactly as the ESC guidelines laid them out.

“I think it will be very interesting for our next stage if we want to try to calibrate [and] maybe we can find other parameters that perhaps can move it closer to 0.7—70% prediction will be much more robust,” he added.