Risk scoring to guide antiplatelet therapy post-percutaneous coronary intervention for acute coronary syndrome results in improved clinical outcomes

Antoniou, Sotiris; Colicchia, Martina; Guttmann, Oliver; Rathod, Krishnaraj S.; Wright, Philip L.; Fhadil, Sadeer; Knight, Charles; Jain, Ajay; Smith, Elliot J.; Mathur, Anthony; Weerackody, Roshan; Wragg, Andrew; Jones, Daniel A.

doi:10.1093/ehjqcco/qcx041

Cited by 11 publications

(13 citation statements)

References 23 publications

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“…Rather, the risk profile can be a tool to inform clinician-patient interactions where clear communication can facilitate reinforcement of, and higher intensity of, risk factor modification. A recent study randomised patients post-ACS to receive clopidogrel (control) or to receive clopidogrel or ticagrelor on the basis of their ischaemic and bleeding risks predicted by the GRACE and CRUSADE scores 28. Patients whose bleeding risk outweighed their need for more potent ischaemic risk reduction received clopidogrel, whereas patients with higher ischaemic risk received ticagrelor.…”

Section: Discussionmentioning

confidence: 99%

Development and validation of a cardiovascular risk score for patients in the community after acute coronary syndrome

Poppe

Doughty

Wells

et al. 2019

Heart

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ObjectiveFollowing acute coronary syndrome (ACS), patients are managed long-term in the community, yet few tools are available to guide patient-clinician communication about risk management in that setting. We developed a score for predicting cardiovascular disease (CVD) risk among patients managed in the community after ACS.MethodsAdults aged 30–79 years with prior ACS were identified from a New Zealand primary care CVD risk management database (PREDICT) with linkage to national mortality, hospitalisation, pharmaceutical dispensing and regional laboratory data. A Cox model incorporating clinically relevant factors was developed to estimate the time to a subsequent fatal or non-fatal CVD event and transformed into a 5-year risk score. External validation was performed in patients (Coronary Disease Cohort Study) assessed 4 months post-ACS.ResultsThe PREDICT-ACS cohort included 13 703 patients with prior hospitalisation for ACS (median 1.9 years prior), 69% men, 58% European, median age 63 years, who experienced 3142 CVD events in the subsequent 5 years. Median estimated 5 year CVD risk was 24% (IQR 17%–35%). The validation cohort consisted of 2014 patients, 72% men, 92% European, median age 67 years, with 712 CVD events in the subsequent 5 years. Median estimated 5-year risk was 33% (IQR 24%–51%). The risk score was well calibrated in the derivation and validation cohorts, and Harrell’s c-statistic was 0.69 and 0.68, respectively.ConclusionsThe PREDICT-ACS risk score uses data routinely available in community care to predict the risk of recurrent clinical events. It was derived and validated in real-world contemporary populations and can inform management decisions with patients living in the community after experiencing an ACS.

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Section: Discussionmentioning

confidence: 99%

Development and validation of a cardiovascular risk score for patients in the community after acute coronary syndrome

Poppe

Doughty

Wells

et al. 2019

Heart

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“…The GRACE score for mortality from admission to six months is most often used for this end. Assessment of the GRACE score can also be used as a quality indicator for quality improvement initiatives [ 4 ], and GRACE-score guided strategies have also shown to reduce MACE rates compared to standard strategies [ 28 ].…”

Section: Risk Scores During Acs Admissionmentioning

confidence: 99%

“…The ESC guideline on NSTE-ACS states that the use of the CRUSADE score may be considered in NSTE-ACS patients undergoing coronary angiography to quantify bleeding risk (class IIb, level of evidence B) [ 5 , 42 ]. A combined GRACE and CRUSADE-score strategy to guide the choice of P2Y12-inhibitor (clopidogrel vs. ticagrelor) significantly lowered the rates of MACE but without a difference in major bleeding [ 28 ]. An almost three-fold greater risk of major bleeding was found in patients with high CRUSADE scores when treated with 24 months versus six months DAPT (9.7% vs. 3.7%; p = 0.04), while no significant differences were found in those with low or intermediate bleeding risk [ 43 ].…”

Section: Risk Scores During Acs Admissionmentioning

confidence: 99%

Risk Assessment Using Risk Scores in Patients with Acute Coronary Syndrome

Yin

Azzahhafi

James

2020

JCM

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Risk scores are widely used in patients with acute coronary syndrome (ACS) prior to treatment decision-making at different points in time. At initial hospital presentation, risk scores are used to assess the risk for developing major adverse cardiac events (MACE) and can guide clinicians in either discharging the patients at low risk or swiftly admitting and treating the patients at high risk for MACE. During hospital admission, risk assessment is performed to estimate mortality, residual ischemic and bleeding risk to guide further in-hospital management (e.g., timing of coronary angiography) and post-discharge management (e.g., duration of dual antiplatelet therapy). In the months and years following ACS, long term risk can also be assessed to evaluate current treatment strategies (e.g., intensify or reduce pharmaceutical treatment options). As multiple risk scores have been developed over the last decades, this review summarizes the most relevant risk scores used in ACS patients.

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“…The CRUSADE Bleeding Risk Score can be used to guide medication selection (e.g., with a higher score, one might choose to delay P2Y 12 inhibition until after the coronary anatomy is defined) or to guide interventional management once selected (e.g., using a radial instead of femoral approach for vascular access). Using validated ischemic and bleeding risk calculations together, especially in conjunction with an echocardiogram, can provide hospitalists with valuable guidance in managing NSTEMI patients [20][21][22].…”

Section: Risk Stratification = Treatment Stratificationmentioning

confidence: 99%

Contemporary NSTEMI management: the role of the hospitalist

Pollack¹,

Amin

Wang

et al. 2020

Hospital Practice

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Non-ST-segment elevation myocardial infarction (NSTEMI) is defined as elevated cardiac biomarkers of necrosis in the absence of persistent ST-segment elevation in the setting of anginal symptoms or other acute event. It carries a poorer prognosis than most ST-segment elevation events, owing to the typical comorbidity burden of the older NSTEMI patients as well as diverse etiologies that add complexity to therapeutic decision-making. It may result from an acute atherothrombotic event ('Type 1') or as the result of other causes of mismatch of myocardial oxygen supply and demand ('Type 2'). Regardless of type and other clinical factors, the hospital medicine specialist is increasingly responsible for managing or coordinating the care of these patients. Following published guidelines for risk stratification and basing anti-anginal, anticoagulant, antiplatelet, other pharmacologic therapies, and overall management approach on that individualized patient risk assessment can be expected to result in better shortand long-term clinical outcomes, including near-term readmission and recurrent events. We present here a review of the evidence basis and expert commentary to assist the hospitalist in achieving those improved outcomes in NSTEMI. Given that the Society for Hospital Medicine cites care of patients with acute coronary syndrome as a core competency for hospitalists, it is essential that those specialists stay current on optimal NSTEMI care. Abbreviations: ACC: American college of cardiology; ACCOAST: comparison of prasugrel at the time of diagnosis in patients with non-ST elevation myocardial infarction; ACS: acute coronary syndrome; ADP: adenosine diphosphate; AHA: American heart association; ARB: angiotensin II receptor blocker; ASA: acetylsalicylic acid; CABG: coronary artery bypass graft: CAD: coronary artery disease; CCTA: coronary computed tomography angiography; cTn: cardiac troponin; CRUSADE: can rapid risk stratification of unstable angina patients suppress adverse outcomes with early implementation of the ACC/AHA guidelines; CURE: clopidogrel in unstable angina to prevent recurrent events; CURRENT: OASIS-7 clopidogrel and aspirin optimal dose usage to reduce recurrent events-seventh organization to assess strategies in ischemic syndromes;

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Risk scoring to guide antiplatelet therapy post-percutaneous coronary intervention for acute coronary syndrome results in improved clinical outcomes

Abstract: Our registry data suggest that using appropriate risk scoring to guide antiplatelet therapy after ACS is safe and can result in improved clinical outcomes.

Cited by 11 publications

References 23 publications

Development and validation of a cardiovascular risk score for patients in the community after acute coronary syndrome

Development and validation of a cardiovascular risk score for patients in the community after acute coronary syndrome

Risk Assessment Using Risk Scores in Patients with Acute Coronary Syndrome

Contemporary NSTEMI management: the role of the hospitalist

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