Achieving Better Risk Prediction and Outcome in Japanese Patients With Acute Myocardial Infarction
Article ID: CJ-21-0797
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Article ID: CJ-21-0797
Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor is the cornerstone of treatment following percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI).1 DAPT reduces ischemic events but increases bleeding. The balance of thrombotic and bleeding risks must be considered for each AMI patient when prescribing DAPT, because both types of events are frequently observed in this population and are independently associated with mortality.1–3 It has been reported that many predictors of thrombotic and bleeding risk overlap, and a large proportion of patients at high risk of thrombosis also have a substantial risk of bleeding.4 Therefore, current guidelines recommend risk assessment for both ischemic and bleeding events, and several risk prediction models have been proposed (Figure).1,5,6 However, the DAPT and PRECISE-DAPT (Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy) scores, which are useful guideline-recommended risk scoring systems to optimize DAPT duration, are unable to separately evaluate ischemic and bleeding risks.5,7,8 Furthermore, although the CREDO-Kyoto (Coronary Revascularization Demonstrating Outcome Study in Kyoto) risk score has recently been proposed for Japanese patients undergoing PCI,4 most risk prediction models have been derived by studies performed in Western countries.5,9 It is unknown whether evidence from Western countries can be generalized to Japanese and East Asian populations, who have different physiques, genetic backgrounds, and medical environments.
PARIS (Patterns of Non-Adherence to Anti-Platelet Regimen in Stented Patients) risk score, CREDO-Kyoto (Coronary Revascularization Demonstrating Outcome Study in Kyoto) risk score, and other assessment tools for thrombotic and bleeding risks. AF, atrial fibrillation; BMI, body mass index; CABG, coronary artery bypass grafting; CKD, chronic kidney disease; CrCl, creatinine clearance; CTO, chronic total occlusion; DAPT, dual antiplatelet therapy; eGFR, estimated glomerular filtration rate; J-HBR criteria, Japanese version of the high bleeding risk criteria; MI, myocardial infarction; PCI, percutaneous coronary intervention; PRECISE-DAPT, Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy; PVD, peripheral vascular disease.
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In this issue of the Journal, Yamashita et al10 retrospectively investigated the predictive ability of the PARIS (Patterns of Non-Adherence to Anti-Platelet Regimen in Stented Patients) and CREDO-Kyoto thrombotic and bleeding risk scores4,9 in Japanese patients with AMI undergoing primary PCI. They showed that: (1) according to these 2 scores, more than 50% of Japanese AMI patients with high bleeding risk had concomitant high thrombotic risk; (2) both PARIS and CREDO-Kyoto risk scores were significantly associated with ischemic and bleeding events after primary PCI; and (3) compared with the PARIS risk score, the CREDO-Kyoto risk score was more discriminative for ischemic events. The variables included in these 2 risk scores are different, indicating that these scores determine patient risks differently. Both the PARIS and CREDO-Kyoto risk scores are useful, but the CREDO-Kyoto risk score developed in Japanese cohorts may have better diagnostic performance in Japanese or East Asian populations. Further large-scale studies are needed to confirm these findings.
Some perspectives should be considered. The Japanese version of the high bleeding risk criteria (J-HBR) has been proposed by adding Japanese-specific factors (low body weight, frailty, heart failure, and peripheral vascular disease) to the Academic Research Consortium High Bleeding Risk (ARC-HBR) criteria.6,11 A recent study demonstrated that the J-HBR criteria identified a higher proportion of patients with high bleeding risk than did the ARC-HBR (64% vs. 48%), and the J-HBR group had significantly higher rates of major bleeding and ischemic events in real-world PCI practice.12 Given the increasing life expectancy in Japan, the prevention of adverse events should take into account factors such as frailty, low body weight, heart failure, and comorbidities.6,13 It would be interesting to evaluate the association between the J-HBR criteria and the CREDO-Kyoto risk score in the development of ischemic and bleeding events. Furthermore, it remains unclear whether the intensity and duration of DAPT after primary PCI based on these risk scores improves clinical outcomes in patients with AMI. The management of patients with high risks of both bleeding and thrombosis is particularly challenging. Just recently, the MASTER DAPT (Management of High Bleeding Risk Patients Post Bioresorbable Polymer Coated Stent Implantation with an Abbreviated vs. Standard DAPT Regimen) trial demonstrated that 1 month of DAPT was non-inferior to the continuation of therapy for at least 2 additional months regarding the occurrence of net adverse clinical events, and that abbreviated therapy resulted in a lower incidence of bleeding.14 In the MASTER DAPT trial, 36.9% of all patients had AMI.14 Further studies are needed to investigate the optimal antithrombotic therapy in AMI patients who are at substantial risk of both thrombosis and bleeding.
K.N. and Y.S. have no conflicts of interest to declare.
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