Risk Stratification Following Percutaneous Coronary Intervention Using the Thrombolysis in Myocardial Infarction Risk Score for Secondary Prevention and a Novel Extension

Background The Thrombolysis in Myocardial Infarction Risk Score for Secondary Prevention (TRS2P) is a well-validated score for predicting recurrent CV events among patients with recent myocardial infarction (MI). The TRS2P design does not account for coronary anatomy or disease complexity, which may provide additional prognostic insight following percutaneous coronary intervention (PCI). Purpose We aimed to evaluate the prognostic performance of TRS2P in a contemporary PCI cohort and determine whether coronary artery disease complexity (c-CAD) addscomplementary risk information. Methods We retrospectively analyzed 22,534 consecutive patients who underwent elective or emergent PCI at a single center between 2004 - 2022. TRS2P was calculated using all 9 components and was categorized into low (0-1), intermediate (2) and high (≥3). To assess the potential incremental value of coronary anatomy, an extended TRS2P-based model (e-TRS2P) was constructed by incorporating c-CAD, defined angiographically as the presence of at least one of the following: left main intervention, multivessel disease including the proximal leftanterior descending artery, chronic total occlusion intervention, implantation of ≥3 stents, or treatment of long lesions requiring a total stent length ≥60 mm. The resulting e-TRS2P was categorized into low (0-1), intermediate (2-3) and high (≥4). Model performance was evaluated using C-statistics and net reclassification improvement (NRI), and associations of TRS2P and e-TRS2P with all-cause mortality and major adverse cardiovascular events (MACE; death, MI, stroke or unstable angina) were evaluated using Cox regression models. Results Overall, 9,855 (44%) and 6,380 (28%) were classified as high TRS2P and high e-TRS2P, respectively. Median follow up was 7.4 years (IQR 3-12). High TRS2P was associated with a greater risk for MACE (HR 3.9, 95% CI 3.7–4.2; p < 0.001) and all-cause mortality (HR 5.6, 95% CI 5.2–6.0; p < 0.001) compared to low TRS2P. Similarly, high vs low e-TRS2P was associated with greater risk of clinical outcomes (HR 5.0, 95% CI 4.7–5.4; p < 0.001, and HR 7.3, 95% CI 6.6–7.9; p < 0.001 for MACE and all-cause mortality, respectively). Incorporation of c-CAD into the TRS2P framework was associated with a modest but statistically significant improvement in discrimination (ΔC = 0.004, 95% CI 0.001–0.007 and ΔC = 0.007, 95% CI 0.004–0.01 for MACE and all-cause mortality, respectively). NRI analysis demonstrated an incremental prognostic value, with correct reclassification of 40% of patients (95%CI: 0.36–0.4, P<0.001 and 95%CI: 0.38–0.5, P<0.001 for MACE and all-cause mortality, respectively) compared with the TRS2P-based model. Conclusions The incorporation of coronary artery disease complexity into the established TRS2P framework was associated with additional improvement in discrimination and risk stratification, correctly reclassifying nearly 40% of patients for both MACE and all-cause mortality.