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The Combined Predictive Value of the GRACE Score and the ARC-HBR Criteria for Bleeding Risk After Percutaneous
Xiaoying Wang1, Yuanyuan Ning2, Xiaojuan Wang1
1Department of Pharmacy, Fuyang People's Hospital, Fuyang, Anhui, 236000, People's Republic of China.
Insights
Combining the Global Registry of Acute Coronary Events (GRACE) score and Academic Research Consortium for High Bleeding Risk (ARC-HBR) criteria improves prediction of bleeding events after percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) patients.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Risk Stratification
Background:
- ST-segment elevation myocardial infarction (STEMI) patients undergoing percutaneous coronary intervention (PCI) face significant bleeding risks.
- Accurate prediction of bleeding is crucial for optimizing patient management and outcomes.
Purpose of the Study:
- To assess the added predictive value of combining the GRACE score with ARC-HBR criteria for post-PCI bleeding risk in STEMI patients.
- To compare the predictive performance of the combined model against individual scores.
Main Methods:
- Prospective observational study of 338 STEMI patients undergoing first-time PCI.
- Bleeding events classified using Bleeding Academic Research Consortium (BARC) criteria.
- Statistical analysis included ROC curves, NRI, IDI, DCA, and calibration plots with internal validation.
Main Results:
- The combined GRACE + ARC-HBR model showed superior predictive performance (AUC 0.774) compared to GRACE alone (0.712) or ARC-HBR alone (0.667).
- The integrated discrimination improvement (IDI) was significant when combining GRACE and ARC-HBR (0.0560 vs GRACE; 0.0768 vs ARC-HBR).
- Decision curve analysis indicated the highest net benefit for the combined model across various threshold probabilities.
Conclusions:
- The combination of GRACE score and ARC-HBR criteria offers incremental predictive value for bleeding events post-PCI in STEMI patients.
- This combined approach enhances risk stratification beyond individual score assessments.
Objective:
To evaluate the incremental predictive value of the Global Registry of Acute Coronary Events (GRACE) score combined with the Academic Research Consortium for High Bleeding Risk (ARC-HBR) criteria for bleeding risk after percutaneous coronary intervention (PCI) in patients with ST‑segment elevation myocardial infarction (STEMI).
Methods:
This prospective observational study enrolled 338 STEMI patients who underwent their first PCI at Fuyang People's Hospital from January 2023 to March 2024. Bleeding events were defined according to the Bleeding Academic Research Consortium (BARC) types 1-5. Patients were stratified by GRACE score (low/middle/high) and ARC‑HBR status (high/low). The predictive performance of the model was assessed using receiver operating characteristic (ROC) curves, net reclassification improvement (NRI), integrated discrimination improvement (IDI), decision curve analysis (DCA), and calibration plots. Internal validation was performed via bootstrap resampling (1,000 iterations).
Results:
Bleeding occurred in 83 patients (24.56%), with 63 in‑hospital events (18.64%) and 34 out‑of‑hospital events (10.06%). The majority were mild (BARC type 1, 82.54% in‑hospital; 73.53% out‑of‑hospital). The combined GRACE + ARC‑HBR model achieved an area under the ROC curve (AUC) of 0.774 (95% CI 0.726-0.818), compared with 0.712 (95% CI 0.660-0.759) for GRACE alone and 0.667 (95% CI 0.614-0.717) for ARC‑HBR alone. Versus GRACE, the combined model showed a non‑significant NRI (-0.0509; P = 0.0945) but a significant IDI (0.0560; P = 0.0006). Versus ARC‑HBR, both NRI (0.3277; P = 0.0007) and IDI (0.0768; P < 0.0001) were significantly positive. DCA demonstrated the highest net benefit for the combined model across most threshold probabilities. The calibration curve yielded a Brier score of 0.147, and the Hosmer-Lemeshow test confirmed good calibration (χ2=3.568, P=0.8938). Bootstrap internal validation produced a bias‑corrected AUC of 0.775.
Conclusion:
Compared with either score alone, the combination of the GRACE score and the ARC-HBR criteria provides incremental predictive value for post-PCI bleeding in STEMI patients.
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