2020 guidelines for the treatment of coronary artery disease in Japan, a list of risk assessment tools.
Since the STARS trial, dual antiplatelet therapy (DAPT) has been the standard treatment after stent implantation. How to select antithrombotic regimens for patients is a difficult problem in clinical practice. We need to assess the risk of thrombosis and bleeding, and consider comprehensively the best antithrombotic treatment for patients. Recently, Japan updated guidelines for antithrombotic treatment of coronary artery disease The risk assessment of thrombosis and bleeding is described, and a variety of commonly used assessment tools in clinical practice are summarized.
Bleeding risk assessment tool
The PRECISE-DAPT score can predict the risk of bleeding during DAPT (12 months after PCI). The DAPT score also assessed the risk of bleeding and thrombosis between 12-30 months after PCI. Table 1 PRECISE-DAPT score and DAPT score Studies have shown that in patients with higher DAPT scores, continued use of DAPT can reduce deaths and cardiovascular events, including myocardial infarction and stroke without increasing bleeding. It is worth noting that the DAPT study excludes patients with bleeding during the first year after PCI, so the score is only applicable to low risk patients who tolerate DAPT for 1 years after PCI. The risk of bleeding and thromboembolic events immediately after PCI is more important than that of PCI after 1 years, but no sufficient evidence has yet been obtained. The PARIS score assessed the risk of thrombus and bleeding outside the stent within 24 months after stent placement. Independent predictors of common bleeding risk included chronic kidney disease (CKD), peripheral vascular disease, heart failure, use of anticoagulants or atrial fibrillation. Low risk: 0-3 points, medium risk 4-7 points, high risk: more than 8 points; Low risk: 0-2 points, medium risk 3-4 points, high risk: more than 5 points.
Thrombosis risk assessment tool
Representative tools for assessing long-term risk of thrombus after PCI include DAPT score and PARIS score. The DAPT score considered the operative factors such as stent diameter, while PARIS score was used only as a predictor of thromboembolic risk after discharge. The 2017ESC guidelines also list predictors of stent thrombosis (Table 5), but their predictive power is unknown. Table 3 predictors of thrombosis in stent
The formation of CREDO-Kyoto risk score for thrombosis and bleeding was based on data from CREDO-Kyoto registration cohort -2 and was validated by data from RESET and NEXT tests. Table 4 CREDO-Kyoto risk score for thrombosis and bleeding Thrombosis risk: more than 4 points, high risk; 2 - 3 points, medium risk; 0 - 1 points, low risk; Bleeding risk: more than 3 points, high risk; 1 - 2 points, medium risk; 0 points, low risk. Severe CKD refers to dialysis or eGFR<30 mL/min/1.73 m2. Other independent bleeding risk factors found in post market surveillance data of prasugrel, Japan include oral NSAIDs, oral anticoagulants, anemia, women, past cerebrovascular diseases (within 30 days after PCI), age (80 years or older), hypertension, and previous gastric ulcer (31 days to 1 years after PCI). Figure 1. assessment of risk factors for thrombosis in Japanese patients Remarks: ACS, acute coronary syndrome, CABG, coronary artery bypass grafting, CKD, chronic kidney disease, CTO, chronic total occlusive disease, DAPT, dual antiplatelet therapy, DES, drug-eluting stent, DM, diabetes mellitus, PCI, percutaneous coronary intervention, PVD, peripheral vascular disease, ST, stent thrombosis.
In May 2019, the 2019 consensus document, defined by the high risk of bleeding academic research alliance (ARC-HBR): the definition of high risk of bleeding in patients undergoing percutaneous coronary intervention, issued 20 criteria for the risk of high bleeding, including 14 main criteria and 6 secondary criteria. The risk of high bleeding is defined as 1 years after PCI, BARC 3 or 5 bleeding risk is more than 4%, or the risk of intracranial hemorrhage is more than 1%. If there are at least 1 main criteria or 2 secondary criteria in the following table, the patient can be considered as HBR. About 20% of PCI patients were at high risk of bleeding. Table 5 major and minor criteria for high risk of bleeding (HBR) during PCI treatment * excluding vascular protective dose. Japanese version of HBR standard added low body weight, weakness, non dialysis CKD and other bleeding risk factors. If at least 1 main criteria or 2 secondary criteria are met, the patient is defined as HBR. Table 6 Japanese version of HBR standard Figure 2 PCI should consider the HBR factor. Remarks: HBR, high risk of bleeding, CKD, chronic kidney disease, ICH, intracranial hemorrhage, NSAIDs, non steroidal anti-inflammatory drugs, PCI, percutaneous coronary intervention, PVD, peripheral vascular disease.
Bleeding risk is a priority.
There are many common risk factors between bleeding and thrombosis. In general, if the risk of bleeding is high, the risk of thrombosis is high. In the CREDO-Kyoto risk score, chronic kidney disease, atrial fibrillation, peripheral vascular disease and heart failure are common risk factors. In other countries and regions, there are many overlapping predictors of bleeding and thrombosis. 2017 the ESC guidelines suggest that the risk of bleeding is a priority in determining the duration of DAPT when formulating antithrombotic regimens, and the risk of thrombosis should not be the first. Compared with Caucasians, East Asian people may have higher risk of bleeding and lower risk of ischemia.
Bibliography index: Masato Nakamura, Kazuo Kimura, Takeshi Kimura, et al. JCS 2020 Guideline Focused Guideline, 2020 Kazuo 13.
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