Clinical utility of the academic research consortium new proposed criteria for high bleeding risk definition in patients with acute coronary syndromes

Background

The Academic Research Consortium High Bleeding Risk (ARC-HBR) criteria have been proposed to stratify the bleeding risk of patients undergoing percutaneous coronary intervention (PCI). While most criteria were established, 4 criteria have been proposed on a de novo basis.

Purpose

We assessed the prevalence and prognosis of new ARC-HBR criteria in a contemporary, prospective, multicenter, quality-improvement registry of all-comers patients with acute coronary syndromes.

Methods

Between 2016 and 2020, consecutive subjects were enrolled; baseline characteristics and medications were prospectively collected, and patients were followed-up at 1 year. All clinical events (including bleeding) were adjudicated by an independent committee. All 17 ARC-HBR criteria were individually evaluated by reviewing patients' charts.

Results

Of the 2804 patients enrolled, 782 (28.0%) met the ARC-HBR definition and 47 (6%) of them experienced a major BARC 3 or 5) bleeding at 1-year. HBR patients had a significantly higher risk of BARC 3–5 bleedings (HR for: 3.07; 95% CI: 2.02–4.67; p<0.0001; Fig. 1A), BARC 2–5 (HR: 1.845; 95% CI: 1.4–2.42; p<0.0001). Fig. 1B indicates the proportion of patients meeting each criterion. Age, (moderate or severe) chronic kidney disease, (moderate or severe) anemia and oral anticoagulant therapy included 88% of HBR patients.

The 4 new ARC-HBR criteria, all together, were present in only 1.7% of our population: 1.0% was planned for major surgery while on dual antiplatelet therapy, 0.5% had a recent intracranial hemorrhage/ictus or brain arteriovenous malformations, 0.1% had hepatic cirrhosis with portal hypertension and 0.1% had a recent surgery or trauma. In a multivariable Cox regression analysis including individual ARC-HBR criteria, only CKD (major and minor criteria), anemia (major and minor criteria) and cancer were the independent predictors of BARC 3–5 events with a concordance-index for this model of 0.698 (p<0.001). In a second model including only CKD (major criterion), anemia (major criterion), age and oral anticoagulation therapy, all these criteria were independent predictors of BARC 3–5 events with a concordance index of 0.674 (pmodel<0.001 for the model) (Fig. 2).

Conclusion

Almost one third of contemporary ACS patients was at HBR according to the ARC-HBR definition and these patients presented a significantly higher risk of bleedings at 1-year. The most common 4 criteria (age, CKD, anemia, and oral anticoagulant therapy) allowed the identification of 88% of HBR patients. The newly proposed HBR criteria were extremely rare and therefore challenging to validate and of uncertain clinical utility. These data may inform and simplify clinical decision making and provide priority for future directions of HBR definitions.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Vascular cerebral anomalies associated with Septo-Optic Dysplasia. A case report

We describe a case of Septo-Optic Dysplasia (SOD) characterized by the presence of anomalous cerebral vessels. In our young patient the classical features of SOD were associated with vascular anomalies including absence of the vein of Galen, right Rosenthal vein leading to the superior petrosal sinus, and anomalous origin of the anterior choroidal arteries. These findings have never been associated with SOD in the literature but their revelation supports the hypothesis of a vascular disruption as a possible cause of the SOD.

Root Rot and Dieback of Pinus pinea Caused by Phytophthora humicola in Tuscany, Central Italy

High mortality was noticed in a 10-year-old stand of Pinus pinea in the Alberese area (Grosseto, central Italy, elev. 40 m, 42° 39' 46″ N, 11° 06' 25″ E) in July 2010. Aerial symptoms of trees included chlorosis, crown thinning, stunted growth, bark lesions at the stem base with resinous exudations, and extensive necroses of the underlying xylem tissue. Woody roots of two uprooted trees exhibited bark necroses and a high proportion of fine roots was destroyed. Soil around necrotic roots was baited using apple fruits (cv. Gala). After 1 week of incubation at 24°C, typical firm fruit rot developed and small tissue samples were transferred to clarified V8 agar (V8A) amended with 5 ml/l PARPNH and incubated at 24°C. After 7 days, stellate to rosaceous, finely lobed cottony colonies arose that were transferred to FPM medium and incubated at 24°C. Within 7 days, spherical oogonia with a smooth surface and predominantly paragynous antheridia formed; sporadic amphyginous antheridia could be observed. Colony squares (1 cm²) were then placed in filtered and sterilized pond water. After 48 h, ovoid, obpyriform, or clavate, nonpapillate, persistent sporangia with internal nested and extended proliferation were formed. Fifty oogonia and 30 sporangia were measured. The diameter of the 50 spherical oogonia varied from 33.6 to 44.9 μm (avg. 39 μm); dimensions of the 30 sporangia were 42.6 to 59.8 × 28.9 to 47.8 μm (avg. 52.95 × 38.98 μm; 1:b ratio 1.37). The isolate was identified as Phytophthora humicola W. H. Ko & Ann on the basis of colony type, size and morphology of oogonia and sporangia, average length/width ratio of sporangia, the homothallic formation of oogonia (4), and ITS rDNA sequence information (GenBank Accession No. JQ757060). A BLAST search of the ITS sequence of P. humicola isolate B33 revealed a 99% identity with the Phytophthora ITS Clade 6 species P. humicola and P. inundata (2). This latter species could be ruled out, however, since it is self-sterile, whereas our isolate B33 was self-fertile (3). A strain of P. humicola was deposited in the CBS-KNAW Fungal Biodiversity Centre, strain no. CBS129249. Pathogenicity tests were conducted on 10 one-year-old twigs of Pinus pinea. A bark portion was removed aseptically and a V8A disc (0.5 cm diam.) of P. humicola mycelium was placed on the wound. Control twigs (3) received sterile V8A discs. Inoculated and control twigs were incubated at 20°C in the dark. Clearly noticeable necrotic lesions (avg. length 2.2 × 0.68 cm) were observed after 15 days on inoculated twigs. Control twigs showed no symptoms. Reisolations on selective V8-PARPNH-agar confirmed P. humicola as the causal agent. P. humicola is mainly associated with woody horticultural crops (1, 3), while the other taxa grouped with this species in Clade 6 are mainly found in forest and riparian ecosystems (1). These aquatic Phytophthora species normally have a saprophytic lifestyle, but under favourable environmental circumstances can act as opportunistic pathogens, attacking susceptible trees and causing scattered mortality in forest stands and natural ecosystems (3). To our knowledge, this is the first report of P. humicola from a pine stand. It is supposed that the pathogen reached the stand through infected plant material or infested soil introduced into the stand. References: (1) C. M. Brasier et al. Mycol. Res. 107:277, 2003. (2) D. E. L. Cooke et al. Fungal Genet. Biol. 30:17, 2000. (3) T. Jung et al. Persoonia 26:13, 2011. (4) W. H. Ko and P. J. Ann. Mycologia 77:631, 1985.

First Report of Neofusicoccum parvum Associated with Bark Canker and Dieback of Acer pseudoplatanus and Quercus robur in Italy

Between 2007 and 2011, Acer pseudoplatanus and Quercus robur trees declined in the North Park and the Boscoincittà Park in Milan, Italy (lat. 45° 27' 47″ N, long. 09° 11' 16″ E, elev. 121 m). Symptoms included extensive lengthwise bark cracks, with necrosis of the wood tissue underneath. Isolations were conducted from bark and infected wood after surface sterilization with 10% H₂O₂ for 10 min, followed by five washings in sterilized water. Tissue was placed on potato dextrose agar (PDA) in petri dishes amended with 0.06 g/l streptomycin at pH 6.5. The dishes were incubated in the dark at 24°C. Colonies reached a diameter of 7 to 8 cm in 7 days. They were whitish grey on the upper surface and blackish at the bottom, and consisted of dense aerial mycelia. The conidia were hyaline, ellipsoid, smooth, non-septate, thin-walled, with their upper end wider than their lower end, and measured 14 to 20 × 4.5 to 7 μm. The causal organism was identified as Neofusicoccum parvum (Pennycook & Samuels) Crous, Slippers & A.J.L. Phillips (basionym Fusicoccum parvum Pennycook & Samuels; teleomorph Botryosphaeria parva Pennycook & Samuels) based on biometric characteristics, common taxonomic keys, and the sequence information from the rDNA ITS region and the elongation factor 1-alpha (EF1-α) gene (GenBank Accession Nos. HQ893535 and HQ893537, respectively). All morphological traits corresponded to those of the holotype (1), while BLAST searches of the GenBank database revealed for both loci 100% homology with reference sequences. To confirm the involvement of N. parvum in the tree death, and fulfil Koch's postulates, 20 2-year-old seedlings of A. pseudoplatanus and Q. robur (10 each) were artificially infected in May with N. parvum in 2008 and in 2009. A bark portion was removed aseptically and a PDA disc (0.5 cm diameter) of N. parvum mycelium was placed on the wound. Control seedlings (3 per species) received sterile PDA discs. The inoculation site was wrapped in Parafilm for 10 days. After 3 weeks, infected seedlings showed sunken bark lesions associated with necrosis and bark cracks. When the bark was stripped, the wood below these lesions was also necrotic. Control seedlings developed no symptoms. Mycelium of N. parvum was successfully reisolated from the infected tissue. N. parvum is an important member of the Botryosphaeriaceae, a family of cosmopolitan endophytes that have been known for many years (2). The pathogen has been in recent years linked to complex syndromes, in which a prominent symptom is the formation of bark cankers. Although common on fruit crops, it has increasingly been reported on forest trees (3,4). References: (1) P. Crous et al. Stud. Mycol. 55:248, 2006. (2) P. A. Saccardo. Michelia 1:1, 1877. (3) M. E. Sánchez et al. Plant Dis. 87:1515, 2003. (4) B. Slippers and M. J. Wingfield. Fung. Biol. Rev. 21:90, 2007.