Lim Carl-Emil, Simonsson Moa, Pasternak Björn, Jernberg Tomas, Edgren Gustaf, Ueda Peter
Division of Clinical Epidemiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.
Division of Cardiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.
JACC Cardiovasc Interv. 2025 Mar 10;18(5):637-650. doi: 10.1016/j.jcin.2024.10.032. Epub 2025 Jan 22.
The aim of the ARC-HBR (Academic Research Consortium for High Bleeding Risk) and PRECISE-DAPT (Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy) score definitions for high bleeding risk is to identify patients who would benefit from shorter or less intensive antiplatelet therapy after coronary stenting.
The aim of this study was to assess the performance of the ARC-HBR and PRECISE-DAPT score definitions for high bleeding risk in routine clinical practice.
Using nationwide registers, all patients in Stockholm, Sweden, who were discharged after coronary stenting with dual antiplatelet therapy (January 1, 2013, to July 1, 2018) were included. Patients were categorized as high bleeding risk according to the 2 risk tools, and risk for bleeding (BARC [Bleeding Academic Research Consortium] types 3-5 or TIMI major or minor) and ischemic events (myocardial infarction or ischemic stroke) within 1 year after discharge was assessed.
Of 7,562 patients, the proportions categorized as high bleeding risk were 27% (2,004 of 7,562) using the ARC-HBR definition and 38% (2,894 of 7,562) using the PRECISE-DAPT score; 22% (1,696 of 7,562) had discordant categorization of high bleeding risk comparing the 2 risk tools. Patients with vs without high bleeding risk according to the ARC-HBR definition had higher risk for BARC type 3 to 5 bleeding (1-year risk 7.1% vs 2.3%; HR: 3.21; 95% CI: 2.47-4.17) and ischemic events (7.8% vs 2.8%; HR: 2.96; 95% CI: 2.31-3.79). Patients with vs without high bleeding risk according to the PRECISE-DAPT score had higher risk for TIMI major or minor bleeding (4.4% vs 2.1%; HR: 2.17; 95% CI: 1.63-2.89) and ischemic events (6.2% vs 2.7%; HR: 2.38; 95% CI: 1.85-3.05). The PRECISE-DAPT score underestimated bleeding risk across almost all score levels (median absolute difference between observed and predicted 1-year risk 1.1%; Q1-Q3: 0.8%-1.4%).
There was substantial discordance in the categorization of high bleeding risk between the ARC-HBR definition and the PRECISE-DAPT score. Both tools identified patients at increased bleeding risk, but those patients also had increased ischemic risk. The PRECISE-DAPT score underestimated bleeding risk. Guideline-recommended high bleeding risk definitions may not be generalizable across patient populations, and refined scoring systems are needed.
ARC-HBR（高出血风险学术研究联盟）和PRECISE-DAPT（预测接受支架植入及后续双联抗血小板治疗患者的出血并发症）评分定义高出血风险的目的是识别那些在冠状动脉支架置入术后可能从更短疗程或强度更低的抗血小板治疗中获益的患者。
本研究旨在评估ARC-HBR和PRECISE-DAPT评分定义在常规临床实践中对高出血风险的评估性能。
利用全国性登记系统，纳入瑞典斯德哥尔摩所有在冠状动脉支架置入术后接受双联抗血小板治疗并出院的患者（2013年1月1日至2018年7月1日）。根据这两种风险评估工具将患者分类为高出血风险，并评估出院后1年内出血（BARC[出血学术研究联盟]3-5型或TIMI大出血或小出血）和缺血事件（心肌梗死或缺血性卒中）的风险。
在7562例患者中，根据ARC-HBR定义分类为高出血风险的比例为27%（7562例中的2004例），根据PRECISE-DAPT评分分类为高出血风险的比例为38%（7562例中的2894例）；比较这两种风险评估工具，22%（7562例中的1696例）患者的高出血风险分类不一致。根据ARC-HBR定义有高出血风险与无高出血风险的患者发生BARC 3至5型出血的风险更高（1年风险7.1%对2.3%；HR：3.21；95%CI：2.47-4.17），缺血事件风险也更高（7.8%对2.8%；HR：2.96；95%CI：2.31-3.79）。根据PRECISE-DAPT评分有高出血风险与无高出血风险的患者发生TIMI大出血或小出血的风险更高（4.4%对2.1%；HR：2.17；95%CI：1.63-2.89），缺血事件风险也更高（6.2%对2.7%；HR：2.38；95%CI：1.85-3.05）。PRECISE-DAPT评分在几乎所有评分水平上都低估了出血风险（观察到的和预测的1年风险之间的中位数绝对差异为1.1%；四分位数间距：0.8%-1.4%）。
ARC-HBR定义和PRECISE-DAPT评分在高出血风险分类方面存在很大差异。两种工具都识别出出血风险增加的患者，但这些患者的缺血风险也增加。PRECISE-DAPT评分低估了出血风险。指南推荐的高出血风险定义可能不适用于所有患者群体，需要完善评分系统。
