Preprocedural HELT-E2S2 scoring identifies high cardiovascular risk after endovascular therapy in patients with lower extremity artery disease

Background The HELT-E2S2 score was originally developed to predict ischemic stroke in patients with atrial fibrillation and has also demonstrated prognostic value for mortality in patients with heart failure. However, its role in patients with lower extremity artery disease (LEAD) undergoing endovascular treatment (EVT) remains unclear. Purpose To evaluate whether the HELT-E2S2 score identifies high-risk patients and predicts clinical outcomes after EVT for symptomatic iliofemoral artery disease. Methods We retrospectively analyzed 240 consecutive patients who underwent EVT between April 2018 and December 2022. The primary endpoint was major adverse cardiovascular events (MACE), defined as all-cause death, nonfatal myocardial infarction, or nonfatal stroke at 3 years. The secondary endpoint was major adverse limb events (MALE), defined as major amputation or target vessel revascularization. Patients were stratified into lower (<2) and higher (≥2) score groups. Multivariable Cox proportional hazards models adjusted for clinically relevant covariates were constructed. Results The mean age was 76.9±10.0 years, and 65.4% were male. Higher-score patients more frequently had non-ambulatory status, prior cerebrovascular disease, and chronic limb-threatening ischemia, reflecting a greater systemic disease burden. During 3-year follow-up, 33 first MACE events occurred (2 in the lower-score group vs. 31 in the higher-score group), including 19 deaths (0 vs. 19), 4 nonfatal myocardial infarctions (0 vs. 4), and 10 nonfatal strokes (2 vs. 8). Three-year freedom from MACE was significantly lower in the higher-score group compared with the lower-score group in the overall cohort and across clinical subgroups, including claudication and ischemic ulcer (80.0% vs. 98.9%, p=0.0002; 80.9% vs. 100%, p=0.012; 59.0% vs. 94.4%, p=0.015, respectively). MALE occurred in 56 patients (25 vs. 31), with no significant difference in 3-year freedom from MALE between groups (68.6% vs. 66.2%, log-rank p=0.70). When cardiovascular and limb events were combined (MACLE), 85 first events were observed (26 vs. 59), and 3-year event-free survival was significantly lower in the higher-score group (49.5% vs. 64.3%, p=0.019). On multivariable analysis, a higher HELT-E2S2 score independently predicted MACE (hazard ratio 3.05, 95% CI 1.22–7.63, p=0.018). Conclusions Preprocedural HELT-E2S2 scoring provides a simple and clinically relevant approach to identify patients at increased cardiovascular risk after EVT for LEAD. This readily available score may facilitate risk-guided management and closer surveillance in high-risk patients.