The value of PRECISE-DAPT score and lesion complexity for predicting all-cause mortality in patients with NSTEMI

Background We aimed to evaluate the prognostic effects of stroke risk scores (SRS), SYNTAX score (SX score), and PRECISE-DAPT score on mortality in patients with non-ST-segment elevation myocardial infarction (NSTEMI). Three hundred forty-three patients hospitalized with a diagnosis of NSTEMI and underwent coronary angiography (CAG) between January 1, 2022, and June 1, 2022, were included retrospectively in this single-center study. Patients' demographic, clinical and routine biochemical parameters were recorded. The scores (CHADS2, CHA2DS2-VASc, R2CHA2DS2-VASc, ATRIA, SX score, PRECISE-DAPT) of each patient were calculated. Participants were then divided into two groups by in-hospital status; all-cause mortality (+) and all-cause mortality (−). Results Overall, the mean age was 63.5 ± 11.8 years, of whom 63.3% (n = 217) were male. In-hospital mortality occurred in 31 (9.3%) patients. In the study population, those who died had significantly higher SX (p < 0.001), PRECISE-DAPT (p < 0.001), and ATRIA (p = 0.002) scores than those who survived. In logistic regression analysis, PRECISE-DAPT score [Odds ratio (OR) = 1.063, 95% CI 1.014–1.115; p = 0.012] and SX score [OR: 1.061, 95% CI 1.015–1.109, p = 0.009] were found to be independent predictors of in-hospital all-cause mortality among NSTEMI patients. In ROC analysis, the PRECISE-DAPT score performed better discriminative ability than the SX score in determining in-hospital mortality [Area under the curve = 0.706, 95% CI 0.597–0.814; p < 0.001]. Conclusions During the hospital stay, both PRECISE-DAPT and SX scores showed better performance than SRS in predicting all-cause mortality among NSTEMI patients undergoing CAG. Aside from their primary purpose, both scores might be useful in determining risk stratification for such patient populations.


Background
The in-hospital prognosis and clinical consequences have become increasingly important as the frequency of acute myocardial infarction (AMI) has risen. Stroke risk scores (SRS), which are frequently used in clinical practice to predict stroke in patients with non-valvular atrial fibrillation, are scoring systems including risk factors similar to coronary artery disease (CAD) [1]. The relation of these scoring systems with mortality in patients with AMI has been shown in many studies [2,3]. Although there are many thromboembolic risk scores, we only evaluated the four most commonly used ones (CHADS 2 , CHA 2 DS 2 -VASc, R 2 CHA 2 DS 2 -VASc, ATRIA) in our study.
PRECISE-DAPT score is another risk scheme developed to predict the risk of bleeding in patients treated with dual antiplatelet therapy after primary percutaneous coronary intervention. Only a few studies have focused on both in-hospital and long-term prognostic outcomes in AMI patients [4,5]. SYNTAX score (SX score) is another scoring system that angiographically evaluates lesion complexity and severity of coronary artery tree. It has been also demonstrated that a high SX score is associated with poor clinical outcomes in patients with acute coronary syndromes [6,7].
Although the effect of many risk factors on the development of mortality in NSTEMI patients has been proven, in this study, we aimed to overcome the lack of a study in the literature that examines and compares the effect of the PRECISE-DAPT, the SX score, and SRS on in-hospital all-cause mortality among patients with NSTEMI undergoing percutaneous coronary intervention.

Study population
This retrospective, single-center, cross-sectional and observational study was performed at the cardiology clinic of Adana City Training and Research Hospital between January 2022 and June 2022. The files of patients admitted to the coronary intensive care unit of the Department of Cardiology with a diagnosis of NSTEMI on the specified dates were retrospectively examined.
The diagnosis of NSTEMI has been made based on current clinical guidelines including positive cardiac markers including high-sensitivity cardiac troponin-I levels (hs-cTnT-I) (the upper limit of troponin-I in our laboratory was 0.16 ng/mL) without ST-segment elevation on routine electrocardiogram [8]. Clinical histories include hypertension (HT) and obstructive pulmonary disease, hyperlipidemia (HL), chronic renal disease (CKD), diabetes mellitus (DM), smoking, peripheral arterial disease, CAD, ischemic stroke/transient ischemic attack (TIA) were obtained and recorded in the national health record system, and medical files of each patient were also captured for retrospective evaluation. We excluded patients with coronary artery bypass graft, chronic obstructive pulmonary disease, severe liver and kidney disease, active cancer, and/or systemic infection (Fig. 1).
Routine blood samples were routinely obtained from all patients in the emergency triage unit or coronary intensive care unit. Laboratory analysis of routine venous blood samples was performed using an automated chemistry analyzer (Roche Diagnostic Modular Systems, Tokyo, Japan). The estimated glomerular filtration rate (eGFR) was measured using the Modification of Diet in Renal Disease formula.

The definitions of scores
The PRECISE-DAPT score was determined for each patient using the web calculator (http:// www. preci sedap tscore. com). Unfortunately, we did not have data on the patients' previous bleeding history; therefore, this parameter could not be included when calculating the score.
CAG was performed on all subjects in our research. The femoral route was used for standard angiograms of the left and right coronary arteries to collect images. Coronary lesions with lumen diameter > 1.5 mm and at least 50% stenosis were analyzed separately, and the SX score was calculated using www. synta xscore. com (version 2.10) [9]. The CHADS 2 score consists of the following parameters; heart failure (HF) (1 point); HT (1 point); age ≥ 75 years (1 point); and history of stroke/TIA, or systemic embolism (2 points). The CHA 2 DS 2 -VASc score is calculated by assigning 2 points for age ≥ 75 years and history of stroke, TIA, or thromboembolism and 1 point for HF, HT, DM, vascular disease aged 65-75 years, and female gender [10]. The R 2 CHA 2 DS 2 -VASc score is determined by adding 2 points to the CHA 2 DS 2 -VASc score for renal failure defined as eGFR below 60 calculated from the Chronic Kidney Disease Epidemiology equation [2]. The ATRIA score assigns one point for the female sex, DM, HT, HF, proteinuria, and kidney dysfunction (eGFR < 45 mL/min/1.73 m2 or end-stage renal disease), and age classes (< 65, 65-74, 75-84, and ≥ 85 years) are assigned different scores based on stroke history (between 0 and 9) [11]. All scores were determined as previously described by two cardiologists blinded to patient survival data. The study population was divided into two groups by in-hospital mortality status: mortality (+) (n = 31) and mortality (−) (n = 312).

Ethics approval and consent to participate
The study was carried out according to the recommendations set forth by the Declaration of Helsinki on biomedical research involving human subjects. The study was approved by the ethics committee of Adana City Training and Research Hospital (date: 08.08.2022, decision No: 2062). Due to the retrospective design, informed consent was not obtained by the ethics committee rules.

Statistical analysis
Data analyses were performed using IBM SPSS Statistics for Windows, Version 22.0 software (IBM Corp., Armonk, NY, USA). Continuous variables with normal distribution have been expressed as mean ± standard deviation, whereas those with abnormal distribution have been expressed as median and interquartile range (IQR). Categorical variables have been expressed as numbers (n) and percentages (%). Student t test or Mann-Whitney U-test was used to compare continuous variables. The Chi-square test or Fisher's exact test was used to compare categorical variables. The odds ratio (OR) and 95% confidence interval (CI) were calculated for each independent variable. Multivariate logistic regression analysis was performed to identify independent predictors of in-hospital all-cause mortality. Variables with significant p values (< 0.05) in univariate analysis were entered into multivariate analysis. The results of univariate and multivariate regression analyses were presented as OR with 95% CI. The area under the curve (AUC) and receiver operating characteristics (ROC) curve analyses were used to examine the prediction accuracy and performance of PRECISE-DAPT and SX scores for in-hospital mortality. Statistical significance has been defined as p < 0.05 throughout the study.

Discussion
The main findings of the present study were as follows: (1) In-hospital mortality occurred in 31 (9.3%) patients with NSTEMI. Those who died were older and had a higher rate of DM. (2) No SRS had effectivity in determining the poor outcome during the hospital stay. PRECISE-DAPT and SX scores, on the other hand, were independent predictors of in-hospital all-cause mortality of NSTEMI patients.
Coronary artery disease-related deaths are among the most common causes of death worldwide. Of AMI patients, NSTEMI is approximately twice as common as ST-elevation myocardial infarction (STEMI) [12]. Inhospital mortality rates of patients with NSTEMI have been reported between 5.2 and 13.1% [13,14]. The effect of many conditions on mortality has been described. Comorbidities such as multivessel disease, advanced age, low Hgb, atrial fibrillation (AF), CKD, diabetes, and history of HF have all been linked to a lower chance of survival in NSTEMI patients [15][16][17].
The PRECISE-DAPT score is determined by analyzing various values available from routine blood tests (Hgb, white blood cell count, and eGFR) and the risks associated with age. The utility of the PRECISE-DAPT score in contexts other than predicting bleeding risk has been investigated. For instance, it has been found that compelling evidence comparable to ours exists in two separate investigations on STEMI and NSTEMI patients that determine in-hospital mortality [5,18]. It has also been researched to find out whether it has any effect on determining long-term prognosis in AMI patients [4].
Although the PRECISE-DAPT score was designed to assess bleeding risk in AMI patients, it was also found to  be more predictive of mortality development than SRS in the present study. The influence of the PRECISE-DAPT score on many AMI complications other than mortality has also been studied in AMI patients. For example, the relationship with the development of periprocedural contrast-induced nephropathy [19], AF, and advanced atrioventricular block [20,21] has been demonstrated in previous reports. Furthermore, the effect on the progression of the no-reflow phenomena in STEMI patients was identified [22]. Except for our study, there are no studies in the literature examining the relationship between PRE-CISE-DAPT and SRS, which are frequently used in routine cardiology practice, and mortality in NSTEMI patients.
The SX score has developed as a reproducible angiographic predictor for measuring the complexity of CAD based on coronary artery tree characteristics. In addition to the fact that the SX score simply represents the complexity of coronary artery lesions, extensive research has been conducted on its association with a variety of conditions in AMI patients [23][24][25]. We showed, similar to the existing literature, the SX score was found to be an independent predictor of mortality in AMI patients [26][27][28][29].
In our analysis, only the ATRIA score from SRS, which includes risk variables similar to CAD and has been used to predict the risk of thromboembolism in patients with non-valvular AF, was statistically higher in non-survivors than in survivors. However, the ATRIA score lost statistical significance in the multivariate regression analysis. Consequently, this is the first study to report that NSTEMI patients with high PRECISE-DAPT and SX scores had significantly higher in-hospital mortality than those with low scores, regardless of the prevalence of concomitant ischemic comorbidities.

Limitations
The retrospective, single-center with a small sample size was the central limitation of the study. Unfortunately, we did not have information on the patient's previous history of bleeding, which is a significant factor in calculating the PRECISE-DAPT score. However, the fact that the strongest prediction among the scores included was in the PRECISE-DAPT score suggests that the result is underestimated at worst. As a result, the implications of the present study should be considered preliminary data. Prospective studies with larger populations should therefore be designed.

Conclusions
This study showed that PRECISE-DAPT and SX scores have more robust evidence than SRS to predict mortality in NSTEMI patients. Thus, using the simple, practical, and widely used PRECISE-DAPT and SX scores not only determines the bleeding risk and extent of the coronary lesion, which have specific applications in the first medical contact, but it may also facilitate prognostic stratification for this patient group.