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... by Costa et al. [1]) and was not associated with worse outcome (p ¼ 0.21), suggesting that elderly patients frequently need complex PCI and that age has a potential confounding role on outcome. In addition, 77% of our cohort exceeded the proposed cutoff for high bleeding risk ( Figure 1A). ...
Context 2
... by Costa et al. [1]) and was not associated with worse outcome (p ¼ 0.21), suggesting that elderly patients frequently need complex PCI and that age has a potential confounding role on outcome. In addition, 77% of our cohort exceeded the proposed cutoff for high bleeding risk ( Figure 1A). ...
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... His calculated score is 26, which denotes a high bleeding risk. Moreover, almost all elderly patients admitted for ACS exceed the proposed cut-off for HBR of the PRECISE DAPT score, due to the very frequent concomitant presence of variables also related to bleeding [67]. ...
Patients ≥ 75 years of age account for about one third of hospitalizations for acute coronary syndromes (ACS). Since the latest European Society of Cardiology guidelines recommend that older ACS patients use the same diagnostic and interventional strategies used by the younger ones, most elderly patients are currently treated invasively. Therefore, an appropriate dual antiplatelet therapy (DAPT) is indicated as part of the secondary prevention strategy to be implemented in such patients. The choice of the composition and duration of DAPT should be tailored on an individual basis, after careful assessment of the thrombotic and bleeding risk of each patient. Advanced age is a main risk factor for bleeding. Recent data show that in patients of high bleeding risk short DAPT (1 to 3 months) is associated with decreased bleeding complications and similar thrombotic events, as compared to standard 12-month DAPT. Clopidogrel seems the preferable P2Y12 inhibitor, due to a better safety profile than ticagrelor. When the bleeding risk is associated with a high thrombotic risk (a circumstance present in about two thirds of older ACS patients) it is important to tailor the treatment by taking into account the fact that the thrombotic risk is high during the first months after the index event and then wanes gradually over time, whereas the bleeding risk remains constant. Under these circumstances, a de-escalation strategy seems reasonable, starting with DAPT that includes aspirin and low-dose prasugrel (a more potent and reliable P2Y12 inhibitor than clopidogrel) then switching after 2–3 months to DAPT with aspirin and clopidogrel for up to 12 months.
... 39 Moreover, most elderly patients admitted for ACS exceed the proposed cut-off for HBR of the PRECISE DAPT score due to the concomitant presence of variables related to bleeding risk. 40 Finally, in the ARC-HBR trade-off model 28 age 65 years is among the four variables related only to major bleeding events ( Table 1). ...
The assessment of bleeding and ischemic risk is a crucial step in establishing appropriate composition and duration of dual antiplatelet therapy (DAPT) in patients with acute coronary syndrome (ACS) treated with percutaneous coronary angioplasty. Evidence from recent randomized clinical trials led to some paradigm shifts in current guidelines recommendations. Options alternative to the standard 12-month DAPT duration include shorter periods of DAPT followed by single antiplatelet treatment with either aspirin or P2Y12 monotherapy, guided or unguided de-escalation DAPT, prolonged DAPT beyond the 12-month treatment period. Although DAPT composition and duration should be selected for each ACS patient on an individual basis weighing clinical and procedural variables, data from latest trials and meta-analyses may permit suggesting the most appropriate DAPT strategy according to the ischemic and bleeding risk assessed using validated tools and scores.
... Most older patients fulfill the criteria for HBR using both ARC criteria and the PRECISE-DAPT score: 120 in the Elderly-ACS 2 trial, two thirds of patients met the ARC-HBR criteria and 77% had a PRECISE-DAPT score >25. 121 Therefore, following guidelines, the great majority of ACS patients with advanced age should be treated with short-term DAPT (3-6 months), preferably using clopidogrel combined with low-dose aspirin. According to the results of the SENIOR trial, this approach should be preferred even in patients receiving a drug-eluting stent. ...
Older patients are underrepresented in prospective studies and randomized clinical trials of acute coronary syndromes (ACS). Over the last decade, a few specific trials have been conducted in this population, allowing more evidence-based management. Older adults are a heterogeneous, complex, and high-risk group whose management requires a multidimensional clinical approach beyond coronary anatomic variables. This review focuses on available data informing evidence-based interventional and pharmacological approaches for older adults with ACS, including guideline-directed management. Overall, an invasive approach appears to demonstrate a better benefit–risk ratio compared to a conservative one across the ACS spectrum, even considering patients’ clinical complexity and multiple comorbidities. Conversely, more powerful strategies of antithrombotic therapy for secondary prevention have been associated with increased bleeding events and no benefit in terms of mortality reduction. An interdisciplinary evaluation with geriatric assessment should always be considered to achieve a holistic approach and optimize any treatment on the basis of the underlying biological vulnerability.
... 4 However, older adults undergoing PCI were underrepresented in validation studies of the ARC HBR score, and its external validity remains unclear in this population. 5 We analyzed a cohort including patients older > 74 years from three large, multicenter prospective studies enrolling subjects with a final diagnosis of acute coronary syndrome (ACS) and undergoing PCI: the randomized clinical trials Elderly-ACS (NCT00510185), 6 Elderly-ACS 2 (NCT01777503), 7 and the prospective GEPRESS study. 8 Bleeding events were adjudicated according to the Bleeding Academic Research Consortium (BARC) scale. ...
... In this regard, bleeding scores like the PRECISE DAPT 31 may be useful, even though in elderly patients, the threshold to indicate HBR is probably higher than that proposed for younger patients. 32 It is important to note, however, that the study population of the Elderly ACS 2 trial had globally a low a priori risk of bleeding, as patients with anaemia, low platelet count, recent (<6 weeks) clinically relevant bleeding, ongoing oral anticoagulant treatment and malignancy were excluded as per trial protocol, and this has to be kept in mind when applying the study results to a real-word elderly ACS population. Further prospective studies are needed to test the proposed personalized treatment, based on optimal temporal balance between ischemic and bleeding risk in this vulnerable population. ...
: The European Society of Cardiology guidelines for myocardial revascularization state that de-escalation of P2Y12 inhibitor treatment guided by platelet function testing may be considered for acute coronary syndrome (ACS) patients deemed unsuitable for 12-month potent platelet inhibition. De-escalation strategy aim is to harmonize the time-dependency of thrombotic risk, which is high in the first month after ACS, then decreases exponentially, with bleeding risk, which tends to remain more stable after the procedure-related peak. Harmonizing time-dependency of clinical events may be particularly relevant in those at high risk, such as the elderly patients with ACS in whom an individualized antiplatelet therapy may be more appropriate than a 'one-size-fits all' approach. In this review, we outline the current medical evidence on the topic of dual antiplatelet therapy de-escalation. In addition, we include insights from the Elderly ACS 2 study and recently published post-hoc analyses conducted by the authors' consortium, which further expands current knowledge.
Background
Contemporary dual antiplatelet therapy (DAPT) strategies, such as short‐term DAPT or de‐escalation of DAPT, have emerged as attractive strategies to treat patients with acute coronary syndrome (ACS). However, it remains uncertain whether they are suitable for elderly patients.
Methods
PubMed, Embase, and Cochrane CENTRAL databases were searched in September 2022. Randomized controlled trials (RCTs) investigating DAPT strategies, including standard (12 months), short‐term, uniform de‐escalation, and guided‐selection strategies for elderly patients with ACS (age ≥ 65 years) were identified, and a network meta‐analysis was conducted. The primary endpoint was the net clinical benefit outcome, a composite of major adverse cardiovascular events (MACEs: cardiovascular death, myocardial infarction, or stroke) and clinically relevant bleeding (equivalent to bleeding of at least type 2 according to the Bleeding Academic Research Consortium). The secondary outcomes were MACE and major bleeding.
Results
Sixteen RCTs with a combined total of 47,911 patients were included. The uniform de‐escalation strategy was associated with an improved net clinical benefit compared with DAPT using potent P2Y 12 inhibitors. The short‐term DAPT strategy was associated with reduced risks of the primary outcome and major bleeding compared with DAPT using potent P2Y 12 inhibitors, however, it was ranked as the least effective strategy for MACE compared with other DAPT strategies.
Conclusions
Uniform de‐escalation and short‐term DAPT strategies may be advantageous for elderly patients, but need to be tailored based on individual bleeding and ischemic risks. Further RCTs of contemporary DAPT strategies specifically designed for elderly patients are warranted to confirm the findings of the present study.
Background
We sought to assess and compare the prediction power of the PRECISE-DAPT and PARIS risk scores with regards to bleeding events in elderly patients suffering from acute coronary syndromes (ACS) and undergoing invasive management.
Methods
Our external validation cohort included 1883 patients older >74 years admitted for ACS and treated with PCI from 3 prospective, multicenter trials.
Results
After a median follow-up of 365 days, patients in the high-risk categories according to the PRECISE-DAPT score experienced a higher rate of BARC 3–5 bleedings (p = 0.002) while this was not observed for those in the high-risk category according to the PARIS risk score (p = 0.3). Both scores had a moderate discriminative power (c-statistics 0.70 and 0.64, respectively) and calibration was accurate for both risk scores (all χ² > 0.05), but PARIS risk score was associated to a greater overestimation of the risk (p = 0.02). Decision curve analysis was in favor of the PRECISE-DAPT score up to a risk threshold of 2%.
Conclusions
In the setting of older adults managed invasively for ACS both the PARIS and the PRECISE-DAPT scores were moderately accurate in predicting bleeding risk. However, the use of the PRECISE-DAPT is associated with better performance.
Aims:
Dual antiplatelet therapy (DAPT) with a P2Y12 inhibitor on top of aspirin is the cornerstone of therapy after acute coronary syndromes (ACS). Nonetheless, the safest and most efficacious P2Y12 for older patients who are both at high ischemic and bleeding risk remains uncertain. We aimed to examine the effect of available P2Y12 inhibitors on ischemic and bleeding endpoints in older adults with ACS.
Methods and results:
Randomized clinical trials that reported separately the results of adults older >70 years for at least the primary endpoint (composite of death, myocardial infarction [MI] and stroke). Seven studies (14,485 patients-years) were included. Network meta-analysis showed that prasugrel was associated with similar occurrence of the primary endpoint and of a secondary ischemic endpoint (composite of MI and stroke) and was most likely the best treatment (Surface Under the Cumulative Ranking curve Analysis [SUCRA] 54.5 and 59.8, respectively). With regards to major bleedings, clopidogrel showed the highest likelihood of event reduction (SUCRA 70.1%) while ticagrelor of stent thrombosis (SUCRA 55.6%). Our meta-regression with a fixed proportion of patients managed invasively of 100% confirmed these trends with increasing SUCRA.
Conclusion:
Among older subjects with ACS, DAPT should be balanced upon ischemic and bleeding risks as prasugrel is associated with the highest probability of reduction of ischemic events and clopidogrel of bleedings. Ticagrelor had highest SUCRA for stent thrombosis reduction but seems suboptimal in older adults.
Bleeding risk stratification is an unresolved issue in older adults. Anemia may reflect subclinical blood losses that can be exacerbated after percutaneous coronary intervention . We sought to prospectively determine the contribution of anemia to the risk of bleeding in 448 consecutive patients aged 75 or more years, treated by percutaneous coronary interventions without concomitant indication for oral anticoagulation. We evaluated the effect of WHO-defined anemia on the incidence of 1-year nonaccess site-related major bleeding. The prevalence of anemia was 39%, and 13.1% of anemic and 5.2% of nonanemic patients suffered a bleeding event (hazard ratio 2.75, 95% confidence interval 1.37 to 5.54, p = 0.004). Neither PRECISE-DAPT nor CRUSADE scores were superior to hemoglobin for the prediction of bleeding. In conclusion, anemia is a powerful predictor of bleeding with potential utility for simplifying tailoring therapies.
