High bleeding risk in acute coronary syndrome means high risk of adverse cardiovascular events

Abstract Background/Introduction Dual antiplatelet therapy (DAPT) is a cornerstone of antithrombotic treatment after percutaneous coronary intervention (PCI) and in patients suffering from acute coronary syndrome (ACS). Every third patient that undergoes PCI belongs to a high bleeding risk (HBR) group, due to burden of comorbidities and previous cardiac conditions. Purpose We sought to compare outcomes regarding major adverse cardiovascular events (MACE) and bleeding events in ACS patients, with or without HBR, undergoing PCI in a tertiary level hospital. Methods The study was retrospective, observational and included consecutive patients admitted for ACS, in a tertiary university hospital from January 2016 to December 2021. Patients were treated with DAPT (aspirin and ticagrelor or clopidogrel). Patients were divided based on bleeding risk according to criteria devised by "The Academic Research Consortium" for HBR. The patients were excluded from the study if they were not suffering from ACS, were in Killip class IV and/or requiring implantation of mechanical circulatory support and/or mechanical ventilation. Patients with significant valve disease and/or previous valve surgery were not included. Results There were 562 HBR and 1284 non-HBR patients. Average age in HBR group was 67±12, vs. non HBR 59±10 years (p0.001), and these patients suffered more frequently from diabetes, peripheral arterial and cerebrovascular disease. Patients in HBR group had lower left ventricular ejection fraction (LVEF) (HBR 38±20%, vs. non-HBR 41±10%, p0.001). They had longer hospital stay (HBR 3.8±4.0 days vs. non-HBR 2.6±3.7 days, p0.001), more in-hospital deaths (HBR n=10 pts., 1.8% vs. non-HBR n=9 pts, 0.7%, p=0.044), and surgical revascularization (HBR n=9, 2% vs. non-HBR n=3, 0.2%, p=0.002). Multivessel disease (MVD) was more often seen in HBR group (HBR n=288 pts, 51% vs. non-HBR n=553 pts, 43%, p=0.003). Patients were followed for median of 1281 days IQR 723 – 1639. MACE occurred more frequently in HBR group (HBR n= 90 (15.5%) vs. non-HBR n=114 (8.9%); p=0.007) mostly due to higher death rate in this group (HBR n=30 pts, 5.3% vs. non-HBR n=28 pts, 2.2 %, p=0.007). HBR status was an independent predictor of MACCE, together with MVD (HR 1.985; 95% CI 1.208 – 3.262; p=0.007). Kaplan-Meier analysis demonstrated that MACCE events occurred more frequently in HBR patients (log-rank p0.001). Conclusion(s) HBR patients present a challenge in ACS and are susceptible to adverse ischemic events. Patient-tailored, precision medicine type intervention in selecting appropriate intervention and antiplatelet regimen becomes imperative.MACCE predictors Kaplan Meier HBR