Validation of the PRECISE-DAPT score in a population-based sample of patients undergoing percutaneous coronary intervention with stent implantation
Authors: Lim C E , Simonsson M , Pasternak B , Jernberg T , Edgren G , Ueda P 
Published: November 2023

Abstract

Background
Dual antiplatelet therapy (DAPT) after coronary stenting reduces the risk of recurrent ischemia but increases bleeding risk. The PRECISE-DAPT score was developed using data from clinical trials to identify individuals at high bleeding risk who may benefit from shorter DAPT duration. Although use of the PRECISE-DAPT score is recommended in clinical guidelines, its applicability to patients seen in routine clinical practice is uncertain.

Purpose
To assess the performance of the PRECISE-DAPT score in a population-based cohort of patients undergoing coronary stenting.

Methods
We calculated the PRECISE-DAPT score in patients enrolled in the Swedish register of cardiac care (SWEDEHEART) who underwent coronary stenting and received DAPT in an urban region in Sweden between January 1, 2013, and December 31, 2018. Patients were followed from day 30 after discharge after coronary stenting until a bleeding event (TIMI major/minor bleeding using ICD-codes for bleeding and data on changes in hemoglobin levels from healthcare registers), an ischemic event (myocardial infarction/ischemic stroke), discontinuation of DAPT, death, 12 months after stenting, or end of study period. We assessed the score’s discrimination and estimated rates of bleeding and ischemic events in groups of patients categorized using the score’s decision rule for "high bleeding risk" (score ≥25). We then compared bleeding rates in groups of patients categorized based on their score with those observed in the clinical trials used to derive the PRECISE-DAPT score.

Results
Of the 8,348 patients (mean (SD) age 67 (11) years; 27% women) included in the study, 2,001 (24%) were categorized as "high bleeding risk" (Figure 1). The PRECISE-DAPT score had a moderate discrimination (c-statistic 0.64, 95% CI, 0.56– 0.71) for bleeding. Patients with "high bleeding risk", compared to those not at "high bleeding risk", had a higher rate of bleeding (2.0 vs 0.9 events per 100 patient years; hazard ratio 2.17, 95% CI 1.29–3.65) and a higher rate of ischemic events (12.8 vs 9.0 events per 100 patient years; hazard ratio, 1.33, 95% CI 1.10–1.61). Patients with "high bleeding risk" in our study population had lower rates of bleeding as compared with those at "high bleeding risk" in the clinical trials used to derive the score. Rates of bleeding in other risk categories were largely similar to those in the clinical trials. (Figure 2).

Conclusion
In a population-based cohort from routine clinical practice in Sweden, the PRECISE-DAPT score identified patients with increased bleeding risk, although those patients also had an increased ischemic risk. Differences in bleeding rates among those categorized as "high bleeding risk" across patient populations may mean that the absolute risk differences in bleeding risk for short vs long DAPT duration demonstrated in the clinical trials used to derive the PRECISE-DAPT score may not be directly applicable to patients seen in routine clinical practice.