Predictive validation of existing bleeding and thromboembolic scores in elderly patients with comorbid atrial fibrillation and acute coronary syndrome

Hong-Hong ZHANG; Qi LIU; Hai-Jing ZHAO; Ya-Ni YU; Liu-Yang TIAN; Ying-Yue ZHANG; Zi-Hao FU; Li ZHENG; Yue ZHU; Yu-Han MA; Shuang LI; Yang-Yang MA; Yu-Qi LIU

doi:10.26599/1671-5411.2023.05.001

Volume 20 Issue 5

May 2023

Turn off MathJax

Article Contents

Article Navigation > Journal of Geriatric Cardiology > 2023 > 20(5): 330-340

Please cite this article as: ZHANG HH, LIU Q, ZHAO HJ, YU YN, TIAN LY, ZHANG YY, FU ZH, ZHENG L, ZHU Y, MA YH, LI S, MA YY, LIU YQ. Predictive validation of existing bleeding and thromboembolic scores in elderly patients with comorbid atrial fibrillation and acute coronary syndrome. J Geriatr Cardiol 2023; 20(5): 330−340. DOI: 10.26599/1671-5411.2023.05.001

Citation:

Please cite this article as: ZHANG HH, LIU Q, ZHAO HJ, YU YN, TIAN LY, ZHANG YY, FU ZH, ZHENG L, ZHU Y, MA YH, LI S, MA YY, LIU YQ. Predictive validation of existing bleeding and thromboembolic scores in elderly patients with comorbid atrial fibrillation and acute coronary syndrome. J Geriatr Cardiol 2023; 20(5): 330−340. DOI: 10.26599/1671-5411.2023.05.001

Citation:

PDF( 2257 KB)

Predictive validation of existing bleeding and thromboembolic scores in elderly patients with comorbid atrial fibrillation and acute coronary syndrome

doi: 10.26599/1671-5411.2023.05.001

Hong-Hong ZHANG^{1, 2},
Qi LIU³,
Hai-Jing ZHAO^{1, 2},
Ya-Ni YU²,
Liu-Yang TIAN^{1, 2},
Ying-Yue ZHANG^{1, 2},
Zi-Hao FU^{1, 2},
Li ZHENG^{1, 2},
Yue ZHU^{1, 2},
Yu-Han MA^{1, 2},
Shuang LI⁴,
Yang-Yang MA⁴,
Yu-Qi LIU^{2, 3
,
,}

1.
Medical School of Chinese PLA, Beijing, China
2.
Department of Cardiology & National Clinical Research Center of Geriatrics Disease; Beijing Key Laboratory of Chronic Heart Failure Precision Medicine; National Key Laboratory of Kidney Diseases, Chinese PLA General Hospital, Beijing, China
3.
Department of Cardiology, the Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
4.
Department of Information, Chinese PLA General Hospital, Beijing, China

More Information

Corresponding author: ametuofo980869@163.com
Publish Date: 2023-05-28

Abstract

Abstract

BACKGROUND The validation of various risk scores in elderly patients with comorbid atrial fibrillation (AF) and acute coronary syndrome (ACS) has not been reported. The present study compared the predictive performance of existing risk scores in these patients. METHODS A total of 1252 elderly patients with AF and ACS comorbidities (≥ 65 years old) were consecutively enrolled from January 2015 to December 2019. All patients were followed up for one year. The predictive performance of risk scores in predicting bleeding and thromboembolic events was calculated and compared. RESULTS During the 1-year follow-up, 183 (14.6%) patients had thromboembolic events, 198 (15.8%) patients had BARC class ≥ 2 bleeding events, and 61 (4.9%) patients had BARC class ≥ 3 bleeding events. For the BARC class ≥ 3 bleeding events, discrimination of the existing risk scores was low to moderate, PRECISE-DAPT (C-statistic: 0.638, 95% CI: 0.611-0.665), ATRIA (C-statistic: 0.615, 95% CI: 0.587-0.642), PARIS-MB (C-statistic: 0.612, 95% CI: 0.584-0.639), HAS-BLED (C-statistic: 0.597, 95% CI: 0.569-0.624) and CRUSADE (C-statistic: 0.595, 95% CI: 0.567-0.622). However, the calibration was good. PRECISE-DAPT showed a higher integrated discrimination improvement (IDI) than PARIS-MB, HAS-BLED, ATRIA, and CRUSADE (P < 0.05) and the best decision curve analysis (DCA). For thromboembolic events, the discrimination of GRACE (C-statistic: 0.636, 95% CI: 0.608-0.662) was higher than CHA2DS2-VASc (C-statistic: 0.612, 95% CI: 0.584-0.639), OPT-CAD (C-statistic: 0.602, 95% CI: 0.574-0.629) and PARIS-CTE (C-statistic: 0.595, 95% CI: 0.567-0.622). The calibration was good. Compared to OPT-CAD and PARIS-CTE, the IDI of the GRACE score slightly improved (P < 0.05). However, NRI analysis showed no significant difference. DCA showed that the clinical practicability of thromboembolic risk scores was similar. CONCLUSIONS The discrimination and calibration of existing risk scores in predicting 1-year thromboembolic and bleeding events were unsatisfactory in elderly patients with comorbid AF and ACS. PRECISE-DAPT showed higher IDI and DCA than other risk scores in predicting BARC class ≥ 3 bleeding events. The GRACE score showed a slight advantage in predicting thrombotic events.

FullText(HTML)

References(40)

References

[1]	Schmitt J, Duray G, Gersh BJ, et al. Atrial fibrillation in acute myocardial infarction: a systematic review of the incidence, clinical features and prognostic implications. Eur Heart J 2009; 30: 1038−1045. doi: 10.1093/eurheartj/ehn579
[2]	Nieuwlaat R, Capucci A, Camm AJ, et al. Atrial fibrillation management: a prospective survey in ESC member countries: the Euro Heart Survey on Atrial Fibrillation. Eur Heart J 2005; 26: 2422−2434. doi: 10.1093/eurheartj/ehi505
[3]	Siu CW, Jim MH, Ho HH, et al. Transient atrial fibrillation complicating acute inferior myocardial infarction: implications for future risk of ischemic stroke. Chest 2007; 132: 44−49. doi: 10.1378/chest.06-2733
[4]	De Luca L, Casella G, Rubboli A, et al. Recent trends in management and outcome of patients with acute coronary syndromes and atrial fibrillation. Int J Cardiol 2017; 248: 369−375. doi: 10.1016/j.ijcard.2017.08.019
[5]	Knuuti J, Wijns W, Saraste A, et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 2020; 41: 407−477. doi: 10.1093/eurheartj/ehz425
[6]	Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021; 42: 373−498. doi: 10.1093/eurheartj/ehaa612
[7]	Kumbhani DJ, Cannon CP, Beavers CJ, et al. 2020 ACC Expert Consensus Decision Pathway for Anticoagulant and Antiplatelet Therapy in Patients With Atrial Fibrillation or Venous Thromboembolism Undergoing Percutaneous Coronary Intervention or With Atherosclerotic Cardiovascular Disease: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2021; 77: 629−658.
[8]	Eagle KA, Lim MJ, Dabbous OH, et al. A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month postdischarge death in an international registry. JAMA 2004; 291: 2727−2733. doi: 10.1001/jama.291.22.2727
[9]	Nieuwlaat R, Prins MH, Le Heuzey JY, et al. Prognosis, disease progression, and treatment of atrial fibrillation patients during 1 year: follow-up of the Euro Heart Survey on atrial fibrillation. Eur Heart J 2008; 29: 1181−1189. doi: 10.1093/eurheartj/ehn139
[10]	Baber U, Mehran R, Giustino G, et al. Coronary Thrombosis and Major Bleeding After PCI With Drug-Eluting Stents: Risk Scores From PARIS. J Am Coll Cardiol 2016; 67: 2224−2234.
[11]	Han Y, Chen J, Qiu M, et al. Predicting long-term ischemic events using routine clinical parameters in patients with coronary artery disease: The OPT-CAD risk score. Cardiovasc Ther 2018; 36: e12441. doi: 10.1111/1755-5922.12441
[12]	Pisters R, Lane DA, Nieuwlaat R, et al. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest 2010; 138: 1093−1100. doi: 10.1378/chest.10-0134
[13]	Fang MC, Go AS, Chang Y, et al. A new risk scheme to predict warfarin-associated hemorrhage: The ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) Study. J Am Coll Cardiol 2011; 58: 395−401. doi: 10.1016/j.jacc.2011.03.031
[14]	Costa F, van Klaveren D, James S, et al. Derivation and validation of the predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score: a pooled analysis of individual-patient datasets from clinical trials. Lancet 2017; 389: 1025−1034. doi: 10.1016/S0140-6736(17)30397-5
[15]	Subherwal S, Bach RG, Chen AY, et al. Baseline risk of major bleeding in non-ST-segment-elevation myocardial infarction: the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines) Bleeding Score. Circulation 2009; 119: 1873−1882. doi: 10.1161/CIRCULATIONAHA.108.828541
[16]	Mehran R, Rao SV, Bhatt DL, et al. Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the Bleeding Academic Research Consortium. Circulation 2011; 123: 2736−2747. doi: 10.1161/CIRCULATIONAHA.110.009449
[17]	DeLong ER, DeLong DM, Clarke-Pearson DL. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics 1988; 44: 837−845. doi: 10.2307/2531595
[18]	Vickers AJ, Van Calster B, Steyerberg EW. Net benefit approaches to the evaluation of prediction models, molecular markers, and diagnostic tests. BMJ 2016; 352: i6.
[19]	Van Calster B, Wynants L, Verbeek JFM, et al. Reporting and Interpreting Decision Curve Analysis: A Guide for Investigators. Eur Urol 2018; 74: 796−804. doi: 10.1016/j.eururo.2018.08.038
[20]	Gibson CM, Mehran R, Bode C, et al. Prevention of Bleeding in Patients with Atrial Fibrillation Undergoing PCI. N Engl J Med 2016; 375: 2423−2434. doi: 10.1056/NEJMoa1611594
[21]	Cannon CP, Bhatt DL, Oldgren J, et al. Dual Antithrombotic Therapy with Dabigatran after PCI in Atrial Fibrillation. N Engl J Med 2017; 377: 1513−1524. doi: 10.1056/NEJMoa1708454
[22]	Lopes RD, Heizer G, Aronson R, et al. Antithrombotic Therapy after Acute Coronary Syndrome or PCI in Atrial Fibrillation. N Engl J Med 2019; 380: 1509−1524. doi: 10.1056/NEJMoa1817083
[23]	Vranckx P, Valgimigli M, Eckardt L, et al. Edoxaban-based versus vitamin K antagonist-based antithrombotic regimen after successful coronary stenting in patients with atrial fibrillation (ENTRUST-AF PCI): a randomised, open-label, phase 3b trial. Lancet 2019; 394: 1335−1343. doi: 10.1016/S0140-6736(19)31872-0
[24]	Yoshida R, Ishii H, Morishima I, et al. Performance of HAS-BLED, ORBIT, PRECISE-DAPT, and PARIS risk score for predicting long-term bleeding events in patients taking an oral anticoagulant undergoing percutaneous coronary intervention. J Cardiol 2019; 73: 479−487. doi: 10.1016/j.jjcc.2018.10.013
[25]	Angiolillo DJ, Goodman SG, Bhatt DL, et al. Antithrombotic Therapy in Patients With Atrial Fibrillation Treated With Oral Anticoagulation Undergoing Percutaneous Coronary Intervention: A North American Perspective-2018 Update. Circulation 2018; 138: 527−536. doi: 10.1161/CIRCULATIONAHA.118.034722
[26]	Valgimigli M, Bueno H, Byrne RA, et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2018; 39: 213−260. doi: 10.1093/eurheartj/ehx419
[27]	Puurunen MK, Kiviniemi T, Schlitt A, et al. CHADS2, CHA2DS2-VASc and HAS-BLED as predictors of outcome in patients with atrial fibrillation undergoing percutaneous coronary intervention. Thromb Res 2014; 133: 560−566. doi: 10.1016/j.thromres.2014.01.007
[28]	Guo T, Xi Z, Qiu H, et al. Prognostic value of GRACE and CHA2DS2-VASc score among patients with atrial fibrillation undergoing percutaneous coronary intervention. Ann Med 2021; 53: 2215−2224.
[29]	Guerrero C, Ariza-Solé A, Formiga F, et al. Applicability of the PRECISE-DAPT score in elderly patients with myocardial infarction. J Geriatr Cardiol 2018; 15: 713−717.
[30]	Wiviott SD, Antman EM, Gibson CM, et al. Evaluation of prasugrel compared with clopidogrel in patients with acute coronary syndromes: design and rationale for the TRial to assess Improvement in Therapeutic Outcomes by optimizing platelet InhibitioN with prasugrel Thrombolysis In Myocardial Infarction 38 (TRITON-TIMI 38). Am Heart J 2006; 152: 627−635. doi: 10.1016/j.ahj.2006.04.012
[31]	Costa F, Valgimigli M, Steg PG, et al. Antithrombotic therapy according to baseline bleeding risk in patients with atrial fibrillation undergoing percutaneous coronary intervention: applying the PRECISE-DAPT score in RE-DUAL PCI. Eur Heart J Cardiovasc Pharmacother 2022; 8: 216−226. doi: 10.1093/ehjcvp/pvaa135
[32]	Shuvy M, Klein E, Cohen T, et al. Value of Adding the CHA2DS2-VASc Score to the GRACE Score for Mortality Risk Prediction in Patients With Acute Coronary Syndrome. Am J Cardiol 2019; 123: 1751−1756. doi: 10.1016/j.amjcard.2019.02.045
[33]	Noubiap JJ, Feteh VF, Middeldorp ME, et al. A meta-analysis of clinical risk factors for stroke in anticoagulant-naive patients with atrial fibrillation. Europace 2021; 23: 1528−1538. doi: 10.1093/europace/euab087
[34]	Ariza-Solé A, Guerrero C, Formiga F, et al. Global Geriatric Assessment and In-Hospital Bleeding Risk in Elderly Patients with Acute Coronary Syndromes: Insights from the LONGEVO-SCA Registry. Thromb Haemost 2018; 118: 581−590. doi: 10.1055/s-0038-1623532
[35]	Singh P, Arrevad PS, Peterson GM, et al. Evaluation of antithrombotic usage for atrial fibrillation in aged care facilities. J Clin Pharm Ther 2011; 36: 166−171. doi: 10.1111/j.1365-2710.2010.01167.x
[36]	Choi HI, Ahn JM, Kang SH, et al. Prevalence, management, and long-term (6-year) outcomes of atrial fibrillation among patients receiving drug-eluting coronary stents. JACC Cardiovasc Interv 2017; 10: 1075−1085. doi: 10.1016/j.jcin.2017.02.028
[37]	Ajam T, Cumpian TL, Tilkens BL, et al. Non-vitamin K antagonist oral anticoagulants for stroke prevention in atrial fibrillation: safety issues in the elderly. Expert Rev Clin Pharmacol 2020; 13: 1309−1327. doi: 10.1080/17512433.2020.1842191
[38]	Guo Y, Kotalczyk A, Imberti JF, et al. Quality indicators in the management of elderly Chinese patients with atrial fibrillation: a report from the Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry. Eur Heart J Qual Care Clin Outcomes 2022; 8: 651−658. doi: 10.1093/ehjqcco/qcab057
[39]	Lamberts M, Gislason GH, Olesen JB, et al. Oral anticoagulation and antiplatelets in atrial fibrillation patients after myocardial infarction and coronary intervention. J Am Coll Cardiol 2013; 62: 981−989. doi: 10.1016/j.jacc.2013.05.029
[40]	Olivier CB, Fan J, Askari M, et al. Site Variation and Outcomes for Antithrombotic Therapy in Atrial Fibrillation Patients After Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2019; 12: e007604. doi: 10.1161/CIRCINTERVENTIONS.118.007604