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

Prognosis and prescriptions of glifozines in candidates patients in a prospective, multicenter, quality-improvement study of patients with acute coronary syndrome

Background

Sodium-glucose transporter 2 inhibitors (SGLT2-i) have demonstrated substantial improvement in clinical outcomes for patients with heart failure (HF) and chronic kidney disease (CKD) with or without diabetes mellitus (DM). Prescription patterns and outcome of SGLT2-i candidates in patients hospitalized for an acute coronary syndrome (ACS) are less well established.

Purpose

We aimed to assess the proportion of candidates to SGLT2-i and to characterize their clinical outcome in a contemporary, prospective, multicenter, quality-improvement study of all-comers patients with ACS. We also aimed to ascertain prescriptions of SGLT2-i at discharge.

Methods

Between 2018 and 2020, subjects were enrolled in the study; baseline characteristics and medications were prospectively collected, and patients were followed-up at 1 year. Subjects were considered candidates to SGLT2-i if any of the following were: (i) known (medically treated) or new (HbA1c >6.5%) diagnosis of type 2 DM; (ii) left ventricular systolic dysfunction (LVSD; new or known left ventricular ejection fraction <40%) or clinical HF; (iii) CKD (estimated glomerular filtration rate 25–74 mL/min/m2, according to DAPA-CKD trial eligibility).

Results

Of the 2804 consecutive ACS patients enrolled, 798 (28.5%) had new or known DM and only 10 were already on SGLT2-I at baseline. Additionally, 1,098 (39.2%) patients qualified for SGLT2-i prescription as having known or new LVSD or HF, and 803 (28.6%) as having CKD. (Fig. 1A) Overall, these 1,767 (63.1%) SGLT2-i candidates had substantially higher hazard of death as compared to no candidate (Hazard Ratio [HR] at 1-year: 6.82; 95% Confidence Interval: 4.32–10.8; p<0.001; Fig. 1B) and each indication to SGLT2-i independently predicted death at 1 year (HR: 2.30/2.11/3.06; 95% CI: 1.78–2.97/1.62–2.74/2.35–3.97; all p<0.0001; for DM, HF, CKD, respectively; Fig. 2). At discharge, only 18 (1.0% of the candidates) were prescribed with SGLT2-i and, of those with DM, having a diabetological consultation before discharged modestly but significantly increased the likelihood of being discharged with SGLT2-i (4.3% vs. 6.6%; p=0.0015).

Conclusion

Most (two out of three) contemporary ACS patients are candidates to SGLT2-i therapy, and they have a significant and substantial higher risk of mortality at 1-year as compared to no candidates. Current prescription rates are still extremely low (1%) and highlight opportunity for quality improvement and multidisciplinary decision-making.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Designing the Model Human Cochlea: An Ambient Crossmodal Audio-Tactile Display

We present a model human cochlea (MHC), a sensory substitution technique and system that translates auditory information into vibrotactile stimuli using an ambient, tactile display. The model is used in the current study to translate music into discrete vibration signals displayed along the back of the body using a chair form factor. Voice coils facilitate the direct translation of auditory information onto the multiple discrete vibrotactile channels, which increases the potential to identify sections of the music that would otherwise be masked by the combined signal. One of the central goals of this work has been to improve accessibility to the emotional information expressed in music for users who are deaf or hard of hearing. To this end, we present our prototype of the MHC, two models of sensory substitution to support the translation of existing and new music, and some of the design challenges encountered throughout the development process. Results of a series of experiments conducted to assess the effectiveness of the MHC are discussed, followed by an overview of future directions for this research.

Effects of relative phases on pitch and timbre in the piano bass range

Piano bass tones raise questions related to the perception of multicomponent, inharmonic tones. In this study, the influence of the relative phases among partials on pitch and timbre was investigated for synthesized bass tones with piano-like inharmonicity. Three sets of bass tones (A0 = 27.5 Hz, 100 partials, flat spectral envelope) were generated; harmonic, low inharmonic, and high inharmonic. For each set, five starting phase relations among partials were applied; sine phases, alternate (sine/cosine) phases, random phases, Schroeder phases, and negative Schroeder phases. The pitch and timbre of the tones were influenced markedly by the starting phases. Listening tests showed that listeners are able to discriminate between tones having different starting phase relations, and also that the pitch could be changed by manipulating the relative phases (octave, fifth, major third). A piano-like inharmonicity gives a characteristic randomizing effect of the phase relations over time in tones starting with nonrandom phase relations. A measure of the regularity of the phase differences between adjacent partials is suggested for quantifying this randomization process. The observed phase effects might be of importance in synthesizing, recording, and reproducing piano music.