Analysis Of Antithrombotic Therapy And Bleeding Risk Model After Atrial Fibrillation Combined With Coronary Stent

Background:Acute coronary syndrome patients with stent implantation,in order to prevent thrombosis in the stent and reduce the recurrence of ischemic cardiovascular events,perioperative and postoperative often choose aspirin combined with P2Y12 receptor antagonist long-term dual antiplatelet therapy(DAPT).Patients with intermediate to high-risk atrial fibrillation(AF)are often treated with long-term anticoagulant drugs to reduce the risk of thromboembolism or cardiovascular and cerebrovascular events.Clinically,the two types of diseases often coexist,and the dual antithrombotic regimens of antiplatelet and anticoagulant drugs needs to be applied,resulting in increased bleeding risk events.Major bleeding can increase the patient’s long-term mortality,which is comparable to the mortality of follow-up recurrent myocardial infarction,so the choice of antithrombotic treatment strategy is closely related to the clinical outcome.How to avoid patients’bleeding events and grasp the balance between bleeding events and ischemic events is the focus of clinicians.In order to evaluate and weigh the risk of bleeding,multiple prediction models of bleeding risk have been established,but most of them are for a single disease,and there is no bleeding risk model for patients with AF after stenting.At the same time,ethnic differences also affect the predictive value of bleeding risk scores.Whether the existing scoring system is applicable to the prediction of bleeding risk in patients with atrial fibrillation and acute coronary syndrome after stenting in China is unclear.Objective:Observe the incidence of major bleeding events(BARC≥3)and major adverse cardiovascular events within 1 year after coronary stenting in patients with atrial fibrillation and acute coronary syndrome;To analyze the correlation between different antithrombotic treatment options(single antiplatelet+anticoagulant drug therapy vs dual antiplatelet+anticoagulant drug therapy)and major bleeding events and major adverse cardiovascular events;To explore the predictive value of the CRUSADE score,HAS-BLED score,and PARIS score for the risk of major bleeding out-of-hospital in patients with atrial fibrillation and acute coronary syndrome.Method:Continually included patients after atrial fibrillation combined with acute coronary syndrome stent implantation in the Department of Cardiology of the First Affiliated Hospital of Chongqing Medical University from April 2017 to June 2019,the clinical data of patients were collected,and all cases were treated with anticoagulation+antiplatelet therapy at the time of discharge.Patients with missing clinical data or substandard were excluded,and 83 patients were included.Corresponding scores were calculated based on CRUSADE score,HAS-BLED score and PARIS score model,and were followed up for 6-12months after discharge,with an average follow-up of 10.3 months.Observe the out-of-hospital major bleeding events(BARC≥3)and major adverse cardiovascular events.Analyze whether there are differences between out-of-hospital major bleeding events and major adverse cardiovascular events in patients with different antithrombotic programs,use Kaplan-Meier method to draw survival curves,and use Log-rank test.Analyze the effectiveness of CRUSADE score,HAS-BLED score,and PARIS score in predicting the occurrence of major bleeding events outside the hospital.Hosmer-Lemeshow test and C statistic assesss the degree of calibration and discriminating ability,and further through the Delong nonparametric test to compare the prediction accuracy of the three bleeding risk scores.Result:83 patients were followed up for an average of 10.3 months.The incidence of major bleeding events out-of-hospital was 3.6%,all of which were gastrointestinal bleeding.The incidence of major cardiovascular events out-of-hospital was 7.2%.Two patients died and four patients suffered from ischemic stroke.CRUSADE score,HAS-BLED score and PARIS score show that there is sufficient calibration ability to predict major out-of-hospital bleeding events in patients with atrial fibrillation and acute coronary syndrome after stent implantation.The three bleeding risk models(CRUSADE score,HAS-BLED score,and PARIS score)were determined by HL test resultsχ~2=3.644,p=0.88,χ~2=0.417,p=1.00,χ~2=3.482,p=0.90;CRUSADE score receiver operating characteristic curve(ROC curve)of the area(AUC)was 0.606,HAS-BLED score AUC was 0.627,PARIS score AUC was 0.600.AUC pairwise comparison:CRUSADE vs HAS-BLED Z=0.326,p=0.744;CRUSADE vs PARIS Z=0.014,p=0.989;HAS-BLED vs PARIS Z=0.053,p=0.957.Conclusion:In patients with atrial fibrillation and acute coronary syndrome after stenting,two antithrombotic strategy compared with three antithrombotic strategy,there was no significant difference in the incidence of major adverse cardiovascular events and major bleeding events.CRUSADE score,HAS-BLED score,and PARIS score are highly calibrated for major bleeding,compared with CRUSADE and PARIS scores,HAS-BLED score has a higher predictive value for the major bleeding risk within 1 year outside the hospital,but there is no significant difference between the three bleeding risk model groups.