PRECİSE-DAPT and DAPT scores and effects on mortality in patients who admitted to the Dokuz Eylül University Cardiology Clinic with acute coronary syndrome and undergo stent implantation

Introduction and Purpose: Prolongation of DAPT, provides a significant reduction in ischemic outcomes, while resulting in a significant increase in major bleeding. The independent increase in mortality because of ischemic and bleeding events, makes it difficult for physicians to make decisions about the type and duration of DAPT. For this reason, international guidelines recommend using risk score tools that allow us to assess the risk of bleeding and ischemia when deciding on DAPT. However, since these risk score tools are not tested with large prospective RCT (Randomized Controlled Trial), their values are controversial. In our research, we aimed to examine the mortality relationship of new risk scores, DAPT and PRECISE-DAPT scores. Method: Between 01.01.2013 and 01.07.2014, 260 patients admitted to Dokuz Eylül University Medical Faculty Cardiology Department (cardiology service and coronary intensive care unit) with ACS and undergo stent implantation were included in our study. The patients' records were retrospectively analyzed through the hospital information system and archive records. These patients were reached through the phone numbers registered on the system. Bleeding history of the patients, duration of DAPT use, history of recurrent Mİ, bleeding history under or after DAPT and drug compliance of the patients were questioned in detail. The patient data record form, which was prepared, was filled out in the form of questions and answers by telephone. Laboratory results, echocardiography and CAG reports of the patients, disease histories were obtained from the information recorded through the system. With these data, PRECISE-DAPT and DAPT scores of patients were calculated. Results: 260 patients were included in our study. PRECISE-DAPT and DAPT scores of patients admitted with ACS were calculated. The number of patients with a PRECISE-DAPT Score ≥ 25 was 62 (23.8%). The number of patients with DAPT Score ≥ 2 was 193 (74.2%). Mortality occurred in 49 (18.8%) patients. Patients with PRECISE-DAPT ≥25 and those with PRECISE-DAPT <25 were compared in terms of mortality and mortality was significantly higher in the high-scoring group [P <0.001 OR 6.94 C (3.53-13.62)]. Patients with DAPT score ≥ 2 and patients with DAPT score below 2 were compared for mortality and mortality was significantly higher in the group with DAPT score below 2 (P=0.021). The patients were divided into 4 groups (PRECISE-DAPT 25 and DAPT ≥ 2, PRECISE-DAPT ≥ 25 and DAPT ≥ 2, PRECISE-DAPT 25 and DAPT 2, PRECISE-DAPT ≥ 25 and DAPT 2) according to PRECISE-DAPT and DAPT score. Mortality was significantly higher regardless of DAPT score in patients with high PRECISE-DAPT scores (p<0.001). PRECISE-DAPT scoring was established as a predictor of bleeding risk to guide DAPT. In our study, we evaluated the relationship between PRECISE-DAPT score and major bleeding and all bleeding. Compared to the group with high PRECISE-DAPT score and the low group, there was no significant difference in all bleeding events (P=0.56) and major bleeding events (P=0.23). In our study, the relationship between all bleeding and major bleeding events and mortality was evaluated. There was no significant difference in mortality (p=0.689) with all bleeding events; but mortality was significantly increased in patients with major bleeding [P=0.025 OR 6.16 (1,33-28,49)]. In our study, patients receiving short (≤ 12 months) and long term (>12 months) DAPT were compared in terms of mortality and bleeding events. Mortality was significantly higher in the group receiving prolonged DAPT compared to shorter DAPT [P = 0.019 OR 2.20 C (1.12-4.30)]. Bleeding events were significantly higher in the long DAPT group [P <0.001 OR 3.77 (1.80-7.9)]. When the relationship of long DAPT with major bleeding events was evaluated, it was observed that BARC3 bleedings were numerically high in the group receiving long DAPT but did not reach statistical significance [p=0.056 OR 4.48 CI (0.975-20.607)]. Conclusion: In our study, which included 260 patients who presented with ACS and were implanted coronary stents; we observed that the patient group with a high PRECISE-DAPT score had a high mortality rate regardless of the DAPT score. It was observed that PRECISE-DAPT score, which was established to predict bleeding, did not have a significant relationship with bleeding events in our study. In our study, the PRECISE-DAPT score failed to predict bleeding events, but it was found to be significantly successful in predicting mortality. It was observed in our study that all bleeding events were not related to mortality, while major bleeding increased mortality. Strong relationship of major bleeding with mortality; the need to identify a patient with a high risk of bleeding. In our study, the relationship of DAPT duration with mortality and bleeding events has been evaluated. It has been observed that long DAPT increases all-cause mortality. Large-scale studies are needed to better understand the reasons for this outcome. There was also a significant increase in bleeding events in patients receiving long DAPT. Optimal DAPT duration remains a controversial issue. Further studies are needed to evaluate the duration of DAPT, the role of risk score tools in guiding treatment, high risk of bleeding, and the treatment of high bleeding and ischemic risk patient. Key words: Dual Antiplatelet Therapy (DAPT), PRECİSE-DAPT, Mortality, Bleeding,