Prevalence and prognostic impact of high ischaemic risk criteria in chronic coronary syndrome patients undergoing PCI

BACKGROUND: A substantial proportion of patients with chronic coronary syndrome (CCS) undergoing percutaneous coronary intervention (PCI) experience recurrent ischaemic events. Guidelines recommend risk stratification at the time of PCI and consideration for prolonged dual antiplatelet therapy in high ischaemic risk (HIR) patients. AIMS: This study aimed to evaluate the prevalence and prognostic impact of guideline-defined HIR criteria in a large, real-world cohort of CCS patients undergoing PCI. METHODS: We retrospectively analysed CCS patients treated with drug-eluting stents at Mount Sinai Hospital between 2012 and 2022. Per the 2024 European Society of Cardiology guidelines on the management of CCS, HIR criteria included left main stenting, stent length >60 mm, diabetes mellitus, chronic kidney disease, bifurcation, and chronic total occlusion (CTO). Prognostic associations were assessed using multivariate Cox regression. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE), including death, myocardial infarction (MI), or stroke. RESULTS: Of 15,336 CCS patients, 10,952 (71.4%) met at least one HIR criterion. Overall, HIR status and most of its individual components, with the exception of bifurcation and CTO, predicted MACCE. Increasing numbers of HIR criteria were significantly associated with higher MACCE (p for trend<0.001), as well as the individual components of death (p for trend<0.001) and MI (p for trend<0.001). CONCLUSIONS: In a real-world CCS cohort, guideline-defined HIR status was associated with increased MACCE. However, as almost three-quarters of patients met at least one HIR criterion, risk stratification accuracy at the time of PCI may have been limited.