1. How to stratify ischemic and
bleeding risks in a given patient?
Albert Ariza Solé
Bellvitge University Hospital. Barcelona, Spain.

2. • No conflicts of interests to declare

3. Thrombotic risk Bleeding risk
Ferreiro JL et al. Thromb Haemost 2010;103:1128-35.
“To maximize the effectiveness of therapy and reduce the hazard of bleeding,
ischaemic and bleeding risks should be evaluated on an individual basis.”
2014 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 2014; 35:2541–2619.

4. Residual thrombotic risk
• Risk for ischemic events after a revascularisation
procedure in patients with ACS.
• Is highly associated to the burden of cardiovascular
risk factors and complexity of coronary artery
disease.

5. Flores-Blanco PJ, et al. Association Between Ischemic and Bleeding Risk Scores and the Use of New P2Y(12) Inhibitors in Patients With Acute Coronary Syndrome.
Rev Esp Cardiol. 2018;71:538-544.
Do we really take into account residual thrombotic risk?
More potent antithrombotic drugs in
patients at lower risk!!

6. 0
5
10
15
20
25
30
0 1 2 3 4 5
Patients(%)
Frequency of multiple active plaque ruptures beyond the culprit lesion
79% of patients have >1 active plaque
n=24
Rioufol G et al. Circulation 2002;106:804–808.
Thrombotic risk and complexity of CAD
Stone GW, et al. N Engl J Med 2011;364:226–235.
• PROSPECT study (n=697)

7. Abu-Assi E, et al. The Risk of Cardiovascular Events After an Acute Coronary Event Remains High, Especially During the First Year, Despite Revascularization.
Rev Esp Cardiol. 2016;69:11-8.
Residual thrombotic risk

8. CRUSADE risk score
Predictor Puntaje
Hematocrito basal 0-9
Aclaramiento creatinina 0-39
Frecuencia cardíaca 0-11
Sexo 0-8
Insuficiencia cardíaca al
ingreso
0-7
Vasculopatía previa 0-6
Diabetes mellitus 0-6
TA sistólica 1-10
Total 1-96
Mehran risk score
Predictor Puntaje
Sexo 0-8
Edad 0-12
Creatinina 0-10
Leucocitos 0-10
Anemia 0-6
Alt ECG/biomarcadores 0-6
Tto antitrombótico -5 - 0
Total -5 - 52
ACTION risk score
Predictor Puntaje
Edad 0-6
Creatinina 0-11
TA sistólica 0-4
Hemoglobina basal 2-17
Frecuencia cardíaca 0-14
Peso 0-5
Sexo 0-4
Anticoagulación oral 0-2
Diabetes mellitus 0-3
IC/shock 0-15
Alteraciones ECG 0-7
Vasculopatía previa 0-3
Total 2-91
Predicting in-hospital bleeding

9. Post discharge bleeding events
• Significant physiopathological differences
• No intravenous drugs
• No invasive procedures
• Time depending variables
• Clinically relevant
• More potent new antiplatelet drugs
• Debated DAPT duration
• Coexisting OAC indication

10. Garay A, et al. Mid Term Bleeding Risk Prediction After an Acute Coronary Syndrome: An Unsolved Question. Rev Esp Cardiol. 2016 ;69:527-9.
Post- discharge bleeding risk
Tools for predicting in-hospital bleeding do not
work when assessing postdischarge bleeding
events.

11. Baber U, et al. Coronary Thrombosis and Major Bleeding After PCI With Drug-Eluting Stents: Risk Scores From PARIS. J Am Coll Cardiol. 2016;67:2224-34.
PARIS score

12. DAPT score
Yeh RW, et al; DAPT Study Investigators.. Development and Validation of a Prediction Rule for Benefit and Harm of Dual Antiplatelet Therapy Beyond 1 Year After
Percutaneous Coronary Intervention. JAMA. 2016;315:1735-49.

13. Yeh RW, et al; DAPT Study Investigators.. Development and Validation of a Prediction Rule for Benefit and Harm of Dual Antiplatelet Therapy Beyond 1 Year After
Percutaneous Coronary Intervention. JAMA. 2016;315:1735-49.

14. Raposeiras-Roubín S, et al. Development and external validation of a post-discharge bleeding risk score in patients with acute coronary syndrome: The BleeMACS score.
Int J Cardiol. 2018;254:10-15.
The BleeMACS score

15. 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.
PRECISE-DAPT score

16. PARIS vs DAPT score
Song L, et al. Validation of contemporary risk scores in predicting coronary thrombotic events and major bleeding in patients with acute coronary syndrome after drug-
eluting stent implantations. Catheter Cardiovasc Interv. 2018;91:573-581.

17. PARIS vs PRECISE-DAPT score
Bianco M, et al. Comparative external validation of the PRECISE-DAPT and PARIS risk scores in 4424 acute coronary syndrome patients treated with prasugrel or ticagrelor.
Int J Cardiol. 2020 Feb 15;301:200-206.

18. Natsuaki M, et al; CREDO‐Kyoto PCI/CABG Registry Cohort 2, RESET, and NEXT trial investigators. Prediction of Thrombotic and Bleeding Events After Percutaneous
Coronary Intervention: CREDO-Kyoto Thrombotic and Bleeding Risk Scores. J Am Heart Assoc. 2018;7(11).
More recent tools

19. SWEDEHEART Score
Simonsson M, et al. Development and Validation of a Novel Risk Score for In-Hospital Major Bleeding in Acute Myocardial Infarction:-The SWEDEHEART Score. J Am Heart Assoc. 2019 Mar 5;8(5):e012157.
doi: 10.1161/JAHA.119.012157.

20. Godschalk TC, et al. A clinical risk score to identify patients at high risk of very late stent thrombosis. J Interv Cardiol. 2018;31:159-169.
Modified DAPT score

21. Prediction of intracranial bleeding
Raposeiras-Roubín S, et al. Incidence, predictors and prognostic impact of intracranial bleeding within the first year after an acute coronary syndrome in patients treated with percutaneous coronary
intervention. Eur Heart J Acute Cardiovasc Care. 2019 May 1:2048872619827471. doi: 10.1177/2048872619827471.

22. What do the guidelines recommend?
2017 ESC Focused Update on DAPT in Coronary Artery Disease, developed in collaboration with EACTS (European Heart Journal 2017 – doi: 10.1093/eurheartj/ehx419)

23. Baber U, et al. Coronary Thrombosis and Major Bleeding After PCI With Drug-Eluting Stents: Risk Scores From PARIS. J Am Coll Cardiol. 2016;67:2224-34.
Overlap of thrombotic and bleeding risk

24. Predictor
Baseline haematocrit
Creatinin clearance
Heart rate
Gender
Heart failure at admission
Peripheral artery disease
Diabetes mellitus
Systolic blood pressure
Predictor
Age
Heart rate
Systolic blood pressure
Killip class
Creatinin
ST abnormalities
Cardiac arrest
Cardiac biomarkers
CRUSADE GRACE
Overlap of predictive factors
Ariza-Solé A, et al. Is it possible to separate ischemic and bleeding risk in patients with non-ST segment
elevation acute coronary syndromes? Int J Cardiol. 2014;171:448-50.

25. Bleeding risk in the elderly SCA
≥ 75 años < 75 años
CRUSADE CRUSADE
MEHRAN MEHRAN
ACTION ACTION
Lower predictive ability
at older ages
Ariza-Solé A, et al. Efficacy of bleeding risk scores in elderly patients with acute coronary syndromes. Rev Esp Cardiol. 2014;67:463-70.

26. Ariza-Solé A, et al Global geriatric assessment and in-hospital bleeding risk in elderly patients with acute coronary syndromes. Insights from the LONGEVO-CA
registry. Thromb Haemost. 2018;118(3):581-590.
Bleeding and geriatric assessment

27. Geriatric assessment and antiplatelet terapy
Aboal J, et al. Comorbidity and low use of new antiplatelets in acute coronary syndrome. Aging Clin Exp Res. 2019 Sep 21. doi: 10.1007/s40520-019-01348-7.

28. PRECISE-DAPT score in the elderly

29. Guerrero C, et al. Applicability of the PRECISE-DAPT score in elderly patients with myocardial infarction. J Geriatr Cardiol. 2018;15:713-717.
PRECISE-DAPT in the elderly
12,4%
13,3%
0%
5%
10%
15%
20%
PRECISE-DAPT<25 PRECISE-DAPT≥25
p=0,913

30. Jang JY, et al. Efficacy and Safety of Guideline-Recommended Risk Score-Directed Dual Antiplatelet Therapy After 2nd-Generation Drug-Eluting Stents. Circ J.
2020;84(2):161-168.
Use of risk scores and outcomes

31. Bleeding risk
Thrombotic risk
GRACE
DAPT
PARIS-tromb
CRUSADE
PRECISE-DAPT
PARIS-bleeding
BleeMACS
DAPT
Anemia
Malignancy
Prior bleeding
Low BMI
CKD
PAD
Diabetes
Killip class, BP, HR
Complexity of CAD
PCI result
Still a clinical challenge

32. Conclusions
• Growing evidence about prediction of post-discharge bleeding
and thrombotic events.
• Several available tools. PRECISE-DAPT y DAPT scores are the
most recommended.
• Residual thrombotic risk is a crucial issue. Including
angiographic data can contribute to enhance risk prediction.
• Selective predictive of risk is still a clinical challenge.
• There is a need to adapt most of these tools to patients at older
ages.

33. Thank you
aariza@bellvitgehospital.cat
@AlbertAriza3