Risk stratification after percutaneous coronary intervention (PCI) is mainly according to demographics and clinical presentation. We sought to investigate the impact of high ischemic risk (HIR) features endorsed by the 2018 ESC/EACTS myocardial revascularization guidelines on clinical outcomes after drug-eluting stents implantation and whether this effect is influenced by high bleeding risk (HBR).

Between January 2013 and December 2013, a total of 10,167 consecutive patients undergoing PCI were prospectively enrolled in Fuwai PCI Registry. Endpoints were target lesion failure (TLF) (comprising cardiac death, target vessel myocardial infarction [MI], and target lesion revascularization] and clinically relevant bleeding (Bleeding Academic Research Consortium [BARC] type 2, 3, or 5 bleeding). Guideline-endorsed HIR features were retrospectively assessed. HBR was defined based on the highest quartile of PARIS bleeding score (≥6 or <6). 

Median follow-up was 29 months. 5149 patients had at least 1 HIR feature (50.6%), who experienced significantly increased risks of TLF (adjusted hazard ratio [HR]: 1.59, 95% confidence interval [CI]: 1.32-1.93; P<0.001) and major adverse cardiac events ([MACE], a composite of cardiac death, MI, or definite/probable stent thrombosis) (HRadjust: 1.96 [1.49-2.58]; P<0.001), compared to those with non-HIR features. In contrast, the risk of clinically relevant bleeding was statistically similar between the 2 groups (HRadjust: 0.85 [0.66-1.09]; P=0.200). There was no statistical interaction between HBR and HIR features in regard to TLF (adjusted P interaction=0.855) and clinically relevant bleeding (adjusted P interaction=0.925).

ESC/EACTS-endorsed HIR criteria were associated with a substantial risk of ischemic events, with no increase in clinically relevant bleeding in routine clinical practice; and theses associations did not seem to be modified by HBR status. More potent antiplatelet therapy may be beneficial for patients with high-risk features of stent-related recurrent ischemic events.