Risk Stratification after an Acute Coronary Syndrome: Significance of Antithrombotic Therapy

Abstract

The impact of the de-escalation strategy of antiplatelet therapy (APT) on the life expectancy after acute coronary syndromes (ACS) and percutaneous coronary intervention (PCI) requires an assessment in real clinical practice. Into the Russian multicentral observational trial (ORACLE II ClinicalTrials.gov number, NCT04068909), 1803 patients with ACS and PCI indications were enrolled. During 12 months of follow-up, 228 all-cause deaths have occurred. The analysis of death predictors was carried out by the classification tree method. Age, an option of antithrombotic therapy, a history of chronic heart failure, and uric acid level had the greatest prognostic value. The death prediction model's sensitivity was 82.1% in the training cohort and 79.2% in the test cohort. During the observation period, ticagrelor was replaced with clopidogrel (APT de-escalation) in 357 patients. The groups of patients with different antiplatelet therapy options were adjusted for clinical parameters by the pseudorandomization method. The de-escalation group had the lowerest all-cause death rate. The incidence of bleeding and recurrent nonfatal coronary events in the study groups did not differ significantly. Thus, the APT regimen's advantage of changing from the maximum in the first weeks after ACS to moderate at follow-up has been confirmed. There is an obvious need to study the possibilities of individualizing antiplatelet therapy in patients after acute coronary syndromes.

Keywords: acute coronary syndrome; antithrombotic therapy; de-escalation; risk predictors.

Conflict of interest statement

Victoria A. Brazhnik—the author declares no conflict of interest. Larisa O. Minushkina reports lecture honoraria from Pfizer, Novo-Nordisk, Servier, ProMed, Boehringer-Ingelheim, and Sandoz. Olga I. Boeva—the author declares no conflict of interest. Niyaz R. Khasanov reports lecture and advisory board honoraria from Boehringer Ingelheim, AstraZeneca, Sanofi Aventis, Bayer, Novartis, Novonordisk, Servier, and Pfizer. Elena D. Kosmacheva reports lecture from Astra-Zeneca, Sanofi, Bayer, Pfizer, Servier, Stada, Beringer Ingelheim, and Amgen. Marina A. Chichkova—the author declares no conflict of interest. Dmitry A. Zateyshchikov reports lecture and advisory board honoraria from Boehringer Ingelheim, AstraZeneca, KRKA, Takeda, Sanofi Aventis, Bayer, Servier, and Pfizer.

Figures

Figure 1

Probabilities of the event development for each terminal node in the optimal classification model. Footnote: HR-heart rate, ASA-acetylsalicylic acid, HF-heart failure, Hb-hemoglobin, SBP-systolic bood pressure.

Figure 2

Relative prognostic significance of clinical predictors of all-cause mortality.

Figure 3

The area under the ROC curves of the all-cause mortality prediction model for patients in the training and test cohorts.

Figure 4

Survival probability at different regimens of APT (Kaplan–Meier analysis).

Figure 5

Survival probability of patients under 67 years depending on the APT options (Kaplan–Meier analysis).

Figure 6

Survival probability of patients over 67 years depending on the APT options (Kaplan–Meier analysis).

Figure 7

Survival probability depending on APT options after pseudorandomization (Kaplan–Meier analysis).