Факторы риска кровотечений у больных с острым коронарным синдромом: данные наблюдательного исследования ОРАКУЛ II

Цель. Выявление факторов риска кровотечений 2-5 типов по шкале BARC у больных, перенесших острый коронарный синдром (ОКС).

Материал и методы. Использованы данные 1502 больных из наблюдательного открытого многоцентрового исследования, ОРАКУЛ II (ОбостРение ишемической болезни сердцА: логиКо-вероятностные пУти прогнозирования течения для оптимизации Лечения) — 894 мужчин (59,5%) и 608 женщин (40,5%), возраст — 65,7±12,9 лет. 560 (37,3%) имели ОКС с подъемом сегмента ST и 942 (62,7%) — ОКС без подъема ST. Кровотечения зарегистрированы у 164 больных (10,9%), в том числе во время индексной госпитализации — у 39 (2,6%), из них тяжелых (типы 3-5) 0,5%, значимых — 1,7% (типы 2-5).

Результаты. В течение года после выписки кровотечения отмечены у 126 (8,4%) больных, больших — 0,8%, значимых — 2,4%. Развитие кровотечений 2-5 типа ассоциировалось с наличием язвенной болезни желудка и двенадцатиперстной кишки, желудочно-кишечным кровотечением в анамнезе, снижением клиренса креатинина, гемоглобина, возрастом больных, применением антикоагулянтов в составе тройной или двойной антитромботической терапии, проведением чрескожных коронарных вмешательств при индексной госпитализации и наличием сердечной недостаточности 2-4 класса по Killip при поступлении. ROC-анализ показал, что прогностическая ценность шкалы риска кровотечений ОРАКУЛ составляет 0,762, чувствительность — 62%, специфичность — 78%.

Заключение. Таким образом, нами на материале рутинной клинической практики создана простая шкала оценки риска кровотечений у больных ОКС.

1. Voss WB, Lee M, Devlin GP, Kerr AJ. Incidence and type of bleeding complications early and late after acute coronary syndrome admission in a New Zealand cohort (ANZACSQI-7). N Z Med J. 2016 Jul 1;129(1437):27-38.

2. Castini D, Centola M, Ferrante G, et al. Comparison of CRUSADE and ACUITY-HORIZONS Bleeding Risk Scores in Patients with Acute Coronary Syndromes. Heart, lung & circulation 2018. doi:10.1016/j.hlc.2018.02.012.

3. Zocca P, Kok MM, van der Heijden LC, et al. High bleeding risk patients with acute coronary syndromes treated with contemporary drug-eluting stents and Clopidogrel or Ticagrelor: Insights from CHANGE DAPT. International journal of cardiology. 2018;268. doi:10.1016/j.ijcard.2018.03.116.

4. Sabbag A, Guetta V, Fefer P, et al. Temporal Trends and Outcomes Associated with Major Bleeding in Acute Coronary Syndromes: A Decade-Long Perspective from the Acute Coronary Syndrome Israeli Surveys 2000-2010. Cardiology. 2015;132(3):163-71. doi:10.1159/000430838.

5. Аверкова А. О., Бражник В. А., Королева О. С., и др. Особенности течения острого коронарного синдрома у молодых больных с гиперлипидемией по данным наблюдательного проекта ОРАКУЛ II. Медицинский вестник Северного Кавказа. 2017;12(1):5-8.

6. Mehran R, Rao SV, Bhatt DL, et al. Standardized Bleeding Definitions for Cardiovascular Clinical Trials. A Consensus Report From the Bleeding Academic Research Consortium. Circulation. 2011 Jun 14;123(23):2736-47. doi:10.1161/CIRCULATIONAHA.110.009449.

7. Guerrero C, Garay A, Ariza-Solé A, et al. Anemia in patients with acute coronary syndromes treated with prasugrel or ticagrelor: Insights from the RENAMI registry. Thromb Res. 2018 May 22;167:142-8. doi:10.1016/j.thromres.2018.05.024.

8. Amin AP, Wang TY, McCoy L, et al. Impact of Bleeding on Quality of Life in Patients on DAPT: Insights From TRANSLATE-ACS. J Am Coll Cardiol. 2016 Jan 5;67(1):59-65. doi:10.1016/j.jacc.2015.10.034.

9. Vaduganathan M, Harrington RA, Stone GW, et al. Short- and long-term mortality following bleeding events in patients undergoing percutaneous coronary intervention: insights from four validated bleeding scales in the CHAMPION trials. EuroIntervention. 2018 Feb 2;13(15):e1841-e1849. doi:10.4244/EIJ-D-17-00723.

10. Manzano-Fernández S, Sánchez-Martínez M, Flores-Blanco PJ, et al. Comparison of the Global Registry of Acute Coronary Events Risk Score Versus the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse outcomes With Early Implementation of the ACC/AHA Guidelines Risk Score to Predict In-Hospital Mortality and Major Bleeding in Acute Coronary Syndromes. Am J Cardiol. 2016 Apr 1;117(7):1047-54. doi:10.1016/j.amjcard.2015.12.048.

11. Abu-Assi E, Raposeiras-Roubin S, Cobas-Paz R, et al. Assessing the performance of the PRECISE-DAPT and PARIS risk scores for predicting one-year out-of-hospital bleeding in acute coronary syndrome patients. EuroIntervention. 2018 Mar 20;13(16):1914-22. doi:10.4244/EIJ-D-17-00550.

12. Song L, Guan C, Yan H, et al. Validation of contemporary risk scores in predicting coronary thrombotic events and major bleeding in patients with acute coronary syndrome after drug-eluting stent implantations. Catheter Cardiovasc Interv. 2018 Feb 15;91(S1):573-81. doi:10.1002/ccd.27468.

13. Godino C, Chiarito M, Donahue M, et al. Midterm and one-year outcome of amphilimus polymer free drug eluting stent in patients needing short dual antiplatelet therapy. Insight from the ASTUTE registry (AmphilimuS iTalian mUlticenTer rEgistry). Int J Cardiol. 2017 Mar 15;231:54-60. doi:10.1016/j.ijcard.2017.01.023.

14. Sharma PK, Chhatriwalla AK, Cohen DJ, et al. Predicting long-term bleeding after percutaneous coronary intervention. Catheter Cardiovasc Interv. 2017 Feb 1;89(2):199- 206. doi:10.1002/ccd.26529.

15. Sibbing D, Aradi D, Jacobshagen C, et al. TROPICAL-ACS Investigators. Guided deescalation of antiplatelet treatment in patients with acute coronary syndrome undergoing percutaneous coronary intervention (TROPICAL-ACS): a randomised, open-label, multicentre trial. Lancet. 2017 Oct 14;390(10104):1747-57. doi:10.1016/S0140-6736(17)32155-4.

16. Hamilos M, Petousis S, Xanthopoulou I, et al. Antiplatelet treatment in diabetic patients with acute coronary syndrome undergoing percutaneous coronary intervention: a GReek AntiPlatElet registry substudy. Coron Artery Dis. 2018 Jan;29(1):53-9. doi:10.1097/MCA.0000000000000547.

17. Vranckx P, White HD, Huang Z, et al. Validation of BARC Bleeding Criteria in Patients With Acute Coronary Syndromes: The TRACER Trial. J Am Coll Cardiol. 2016 May 10;67(18):2135-44. doi:10.1016/j.jacc.2016.02.056.

18. Biscaglia S, Campo G, Pavasini R, et al. Occurrence, causes, and outcome after switching from ticagrelor to clopidogrel in a real-life scenario: data from a prospective registry. Platelets. 2016 Jul;27(5):484-7. doi:10.3109/09537104.2015.1119815.7.

19. Rao SV, Jollis JG, Harrington RA, et al. Relationship of blood transfusion and clinical outcomes in patients with acute coronary syndromes. Jama 2004, 292(13):1555-62.

20. Budaj A, Eikelboom JW, Mehta SR, et al. Improving clinical outcomes by reducing bleeding in patients with non-ST-elevation acute coronary syndromes. European heart journal. 2009;30(6):655-61.

21. Ducrocq G, Schulte PJ, Budaj A, et al. Balancing the risk of spontaneous ischemic and major bleeding events in acute coronary syndromes. Am Heart J. 2017 Apr;186:91-99. doi:10.1016/j.ahj.2017.01.010.

22. Stahli BE, Wischnewsky MB, Jakob P, et al. Predictive value of the age, creatinine, and ejection fraction (ACEF) score in patients with acute coronary syndromes. International journal of cardiology 2018. doi:10.1016/j.ijcard.2018.05.134.

23. Stucchi M, Cantoni S, Piccinelli E, et al. Anemia and acute coronary syndrome: current perspectives. Vasc Health Risk Manag. 2018 May 30;14:109-118. doi:10.2147/VHRM.S140951.

24. Valgimigli M, Costa F, Lokhnygina Y, et al. Trade-off of myocardial infarction vs. bleeding types on mortality after acute coronary syndrome: lessons from the Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome (TRACER) randomized trial. Eur Heart J. 2017 Mar 14;38(11):804-810. doi:10.1093/eurheartj/ehw525.

25. Caneiro-Queija B, Abu-Assi E, Raposeiras-Roubin S, et al. Differential Prognostic Impact on Mortality of Myocardial Infarction Compared With Bleeding Severity in Contemporary Acute Coronary Syndrome Patients. Rev Esp Cardiol (Engl Ed). 2018 Oct;71(10):829-836. doi:10.1016/j.rec.2018.02.008.

26. Raposeiras-Roubin S, Faxen J, Iniguez-Romo A, et al. Development and external validation of a post-discharge bleeding risk score in patients with acute coronary syndrome: The BleeMACS score. Int J Cardiol. 2018 Mar 1;254:10-15. doi:10.1016/j.ijcard.2017.10.103.

27. Alraies MC, Lee SY, Lipinski MJ, et al. Effect of Bleeding Risk on Type of Stent Used in Patients Presenting With Acute Coronary Syndrome. The American journal of cardiology. 2017;120(8):1272-8.

28. Alfredsson J, Neely B, Neely ML, et al. Predicting the risk of bleeding during dual antiplatelet therapy after acute coronary syndromes. Heart (British Cardiac Society) 2017, 103(15):1168-76.

29. Baber U, Mehran R, Giustino G, et al. Coronary Thrombosis and Major Bleeding After PCI With Drug-Eluting Stents: Risk Scores From PARIS. J Am Coll Cardiol 2016, 67(19):2224-34.

30. Rivera-Caravaca JM, Ruiz-Nodar JM, Tello-Montoliu A, et al. Disparities in the Estimation of Glomerular Filtration Rate According to Cockcroft-Gault, Modification of Diet in Renal Disease-4, and Chronic Kidney Disease Epidemiology Collaboration Equations and Relation With Outcomes in Patients With Acute Coronary Syndrome. J Am Heart Assoc. 2018;7(9).

31. Subherwal S, Bach RG, Chen AY, et al. Baseline risk of major bleeding in non-ST-segmentelevation myocardial infarction: the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines) Bleeding Score. Circulation. 2009;119(14):1873-82.

32. Mathews R, Peterson ED, Chen AY, et al. In-hospital major bleeding during ST-elevation and non-ST-elevation myocardial infarction care: derivation and validation of a model from the ACTION Registry(R)-GWTG. The American journal of cardiology. 2011;107(8):1136-43.

33. Widimsky P, Motovska Z, Bolognese L, et al. Predictors of bleeding in patients with acute coronary syndromes treated with prasugrel. Heart (British Cardiac Society) 2015;101(15):1219-24.