Do the ARC-HBR criteria predict major bleeding and ischaemic events in an all-comer AMI population? Insights from the MINAP and SWEDEHEART registries

Background A significant proportion of patients with acute myocardial infarction (AMI) have characteristics of high-bleeding -risk (HBR). The prevalence of HBR features and whether these influence ischaemic and bleeding-events in AMI all-comers is not well described. Methods AMI Patients in England and Wales (E&W), and Sweden (S) between 2005 and 2019 were included from MINAP and SWEDEHEART national AMI registries. Patients were categorised according to the Academic Research Consortium for HBR criteria (ARC-HBR). Primary outcomes were MACE (major adverse cardiovascular events) and major-bleeding events, secondary outcomes all-cause and cardiovascular mortality, all at five-years. Secondary analyses evaluated medically managed and invasively managed patients. Results 563,251 AMI patients from E&W (39% HBR) and 189,102 from Sweden (S) (39% HBR) were included. Risk of MACE (E&W: adjusted Hazard ratio (aHR) 2.99, 95% CI [2.95-3.02], S: 2.68 [2.64-2.73]) and major- bleeding events (E&W: 2.28 [2.21-2.35], S: 2.71 [2.58-2.85]) was higher in HBR-patients (all P<0.001). MACE was more likely in both medically-managed (E&W: 3.24 [3.19-3.29], S: 2.31 [2.26-2.37]) and invasively-managed (E&W: 2.94 [2.88-3.00], S: 1.98 [1.92-2.04]) HBR-patients (both P<0.001), as were major-bleeding events in medical (E&W: 2.28 [2.19-2.37], S: 1.35 [1.25-1.45]) (both P<0.001) and invasive groups (E&W: 2.25 [2.15-2.35], P<0.001), S: 1.41 [1.29-1.54], P=0.024). Conclusions In an all-comer AMI population, 1 in 3 patients meet HBR criteria. HBR patients had significantly higher rates of MACE and major bleeding events, which persisted whether managed invasively or medically. We show that the ARC-HBR criteria are associated with increased bleeding and MACE risk in an all-comer AMI population.