Valgimigli, Marco

Background A contemporary, comprehensive risk score for the prediction of in‐hospital fatal and nonfatal adverse events after percutaneous coronary intervention has been recently developed, albeit its external validation in patients with acute coronary syndrome is lacking. The objective of this study is to validate the Mayo Clinic integer risk score in a large cohort of patients with acute coronary syndrome undergoing percutaneous coronary intervention from the MATRIX (Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox) trial. Methods The risk score is composed of a common set of 23 clinical and procedural variables (model A) and 18 preprocedural variables (model B). The primary objective was to appraise the receiver‐operator characteristics of both models for in‐hospital mortality, bleeding, contrast‐associated acute kidney injury, and stroke. The impact of risk score categories on 1‐year outcomes was also investigated. Results Among the 6724 patients undergoing percutaneous coronary intervention in the MATRIX trial, the receiver‐operator characteristics—area under the curves for in‐hospital mortality, bleeding, contrast‐associated acute kidney injury, and stroke were 0.88 (95% CI, 0.85–0.91), 0.66 (95% CI, 0.63–0.69), 0.70 (95% CI, 0.67–0.72), and 0.65 (95% CI, 0.52–0.78) for model A and 0.88 (95% CI, 0.84–0.92), 0.63 (95% CI, 0.60–0.66), 0.66 (95% CI, 0.63–0.69), and 0.65 (95% CI, 0.52–0.78) for model B, respectively. Mortality (model A), bleeding, and stroke risks were well calibrated, whereas mortality (model B) and contrast‐associated acute kidney injury risk were underestimated. There was a gradual risk increase for 1‐year mortality and bleeding as a function of the risk score tertile using both models. Conclusions The risk score identifies patients with acute coronary syndrome at incremental risk of in‐hospital mortality, bleeding, contrast‐associated acute kidney injury, and stroke, representing a valuable tool for mitigation of modifiable risk factors. Registration URL: https://www.clinicaltrials.gov ; Unique Identifier: NCT01433627.

Antiplatelet therapy is the mainstay of pharmacologic treatment to prevent thrombotic or ischemic events in patients with coronary artery disease treated with percutaneous coronary intervention and those treated medically for an acute coronary syndrome. The use of antiplatelet therapy comes at the expense of an increased risk of bleeding complications. Defining the optimal intensity of platelet inhibition according to the clinical presentation of atherosclerotic cardiovascular disease and individual patient factors is a clinical challenge. Modulation of antiplatelet therapy is a medical action that is frequently performed to balance the risk of thrombotic or ischemic events and the risk of bleeding. This aim may be achieved by reducing (ie, de-escalation) or increasing (ie, escalation) the intensity of platelet inhibition by changing the type, dose, or number of antiplatelet drugs. Because de-escalation or escalation can be achieved in different ways, with a number of emerging approaches, confusion arises with terminologies that are often used interchangeably. To address this issue, this Academic Research Consortium collaboration provides an overview and definitions of different strategies of antiplatelet therapy modulation for patients with coronary artery disease, including but not limited to those undergoing percutaneous coronary intervention, and consensus statements on standardized definitions.