Predictive validation of existing bleeding and thromboembolic scores in elderly patients with comorbid atrial fibrillation and acute coronary syndrome

BACKGROUND The validation of various risk scores in elderly patients with comorbid atrial fibrillation(AF) and acute coronary syndrome(ACS) has not been reported. The present study compared the predictive performance of existing risk scores in these patients.METHODS A total of 1252 elderly patients with AF and ACS comorbidities(≥ 65 years old) were consecutively enrolled from January 2015 to December 2019. All patients were followed up for one year. The predictive performance of risk scores in predicting bleeding and thromboembolic events was calculated and compared.RESULTS During the 1-year follow-up, 183(14.6%) patients had thromboembolic events, 198(15.8%) patients had BARC class ≥2 bleeding events, and 61(4.9%) patients had BARC class ≥ 3 bleeding events. For the BARC class ≥ 3 bleeding events, discrimination of the existing risk scores was low to moderate, PRECISE-DAPT(C-statistic: 0.638, 95% CI: 0.611-0.665), ATRIA(C-statistic:0.615, 95% CI: 0.587-0.642), PARIS-MB(C-statistic: 0.612, 95% CI: 0.584-0.639), HAS-BLED(C-statistic: 0.597, 95% CI: 0.569-0.624)and CRUSADE(C-statistic: 0.595, 95% CI: 0.567-0.622). However, the calibration was good. PRECISE-DAPT showed a higher integrated discrimination improvement(IDI) than PARIS-MB, HAS-BLED, ATRIA, and CRUSADE(P < 0.05) and the best decision curve analysis(DCA). For thromboembolic events, the discrimination of GRACE(C-statistic: 0.636, 95% CI: 0.608-0.662) was higher than CHA2DS2-VASc(C-statistic: 0.612, 95% CI: 0.584-0.639), OPT-CAD(C-statistic: 0.602, 95% CI: 0.574-0.629) and PARIS-CTE(C-statistic: 0.595, 95% CI: 0.567-0.622). The calibration was good. Compared to OPT-CAD and PARIS-CTE, the IDI of the GRACE score slightly improved(P < 0.05). However, NRI analysis showed no significant difference. DCA showed that the clinical practicability of thromboembolic risk scores was similar.CONCLUSIONS The discrimination and calibration of existing risk scores in predicting 1-year thromboembolic and bleeding events were unsatisfactory in elderly patients with comorbid AF and ACS. PRECISE-DAPT showed higher IDI and DCA than other risk scores in predicting BARC class ≥ 3 bleeding events. The GRACE score showed a slight advantage in predicting thrombotic events.