Optimal balancing of ischemia-bleeding risk in ACS-PCI: 2 risk calculators and 4 score indexes

Sunil Rao, MD explains ischemic-bleeding risk calculators and tailored APT strategy for ACS patients undergoing PCI at TCTAP 2022

  • ACS patients undergoing percutaneous coronary intervention need both ischemic and bleeding risk assessment before the procedure, an expert said.
  • Tools for calculating procedural risk like the SCAI PCI Risk Calculator and CathPCI Bleeding Risk Calculator can help classify ischemic-bleeding risk and reduce peri-procedural complications.
  • Indexes like the DAPT score, PRECISE-DAPT score, PARIS Registry score and HBR-ARC criteria can help identify targets for tailored APT and lower the risk of long-term bleeding.

Risk assessment tools can help examine bleeding and ischemic risk for patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) to modify both procedural strategy and antiplatelet therapy (APT), an expert said.

“ACS patients undergoing PCI are at elevated risk for adverse procedural events, and some studies have shown the group to be at the highest risk for complications,” Sunil Rao, MD (Duke University Medical Center, North Carolina, USA) said at the 27th TCTAP 2022 on Apr 27.

“The balance of ischemic and bleeding risk should begin before PCI,” Rao said. “For this high-risk group, interventional cardiologists can use risk stratification tools to predict outcomes and intervene at the procedural and post-procedural level.”

Peri-procedural risk calculators to predict PCI outcomes

For key calculators to predict bleeding during PCI, Rao highlighted both the SCAI PCI Risk Calculator and CathPCI Bleeding Risk Calculator.

The SCAI PCI Risk Calculator, developed by the Society for Cardiovascular Angiography and Interventions (SCAI) in 2014, is a mobile application that calculates the risk of in-hospital mortality, blood transfusion and contrast-induced nephropathy (CIN).

The CathPCI Bleeding Risk Calculator, developed by the American College of Cardiology (ACC), aids assessment of PCI-related bleeding risk by pulling data from the CathPCI Registry - the largest ongoing PCI registry worldwide.

“We can use risk stratification tools to define patients at high-risk, and then use the information to formulate interventional strategies that reduce the risk for both ischemic and bleeding,” Rao said. “The calculation should aid strategy selection and ultimately reduce procedural bleeding risks while maximizing ischemic benefits.”

Post-procedural risk scores to tailor APT

Achieving favorable outcomes in ACS-PCI also requires post-procedural APT management, Rao said, entailing another balancing act between bleeding-ischemic risk.

Antiplatelet agents (such as aspirin) and P2Y12 inhibitors (clopidogrel, prasugrel, and ticagrelor) are essential to reduce the risk of thrombosis for ACS-PCI. However, APT could also raise the risk of bleeding, prompting a juggling act of therapies.

“With PCI-APT strategy, we’re balancing the long-term risks of recurrent myocardial infarction (MI) and stent thrombosis with the risk of bleeding complications,” Rao said. “Therefore, a major area of focus is adjusting both the combination and duration of antithrombotic agents.”

The most common APT strategies are single APT (SAPT) with aspirin alone, dual antiplatelet therapy (DAPT) with aspirin and P2Y12 inhibitors, or triple therapy that combines DAPT with an oral anticoagulant (OAC) like vitamin K antagonist or direct oral anticoagulant (DOAC).

ACS-PCI studies have shown that DAPT carries a higher risk of bleeding than SAPT. Shorter DAPT duration was also associated with better outcomes. For patients requiring OAC therapy, dropping the aspirin from triple therapy can cut long-term bleeding risks, Rao said.

To determine which patients would benefit from shorter or less APT, Rao stressed the use of bleeding indexes such as the DAPT score, PRECISE-DAPT score and PARIS Registry score to identify risks of DAPT-related bleeding and ischemic complications.

Notably, the Academic Research Consortium for High Bleeding Risk (ARC-HBR) - developed to provide a consensus on risk stratification - simplifies the process by grouping HBR patients by bleeding risk, he said.

The ARC-HBR criteria, also available as an app, incorporates multiple comorbid conditions and demographic data often not captured in pivotal RCTs and provides a prediction model to assess outcomes related to bleeding, MI and stent thrombosis.

“There are options to maximize benefits and minimize harm at every step of the treatment pathway,” Rao said. “It’s important to assess for high bleeding risk characteristics, employ best PCI practices like radial access and intracoronary imaging, and consider post-PCI APT strategies like P2Y12 monotherapy.”


Edited by

Hanbit Park
Hanbit Park , MD

GangNeung Asan Hospital, Korea (Republic of)

Written by

YoonJee Marian Chu
YoonJee Marian Chu, Medical Journalist
Read Biography
Rao disclosed no industry relationships since March 2018.
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