Exploring the Incremental Value of CRUSADE Score as Clinical Guidance for the Decision-Making of Dual Antiplatelet Therapy Duration: A Retrospective Analysis from the (Prolonging Dual Antiplatelet Treatment After Grading Stent-Induced Intimal Hyperplasia) PRODIGY Trial Pathway

background: Multiple scores have been proposed to stratify bleeding risk in selected patient populations but they are rarely applied in practice and it is unclear if their results may guide decision-making on duration of dual antiplatelet therapy (DAPT). We compared the predictive performance of the CRUSADE, ACUITY and HAS-BLED scores in an all-comer population undergoing coronary stenting and further assessed their incremental value for bleeding events with respect to DAPT duration methods: The prognostic value of the bleeding scores was assessed with a Cox regression model and Harrell C statistic. The additional discriminative and reclassification value of CRUSADE score beyond the ACUITY and HAS-BLED was appraised by the integrated discrimination improvement (IDI). Results: All three bleeding scores were available in 1,946 patients recruited in the PRODIGY trial which randomized all comer PCI patients to receive 6 or 24 month DAPT. Transitioning from a lower to a higher bleeding risk category carried a significant bleeding hazard irrespective of the bleeding score and bleeding definition, with no statistical interaction. The C-statistic was higher for the CRUSADE score vs. ACUITY or HAS-BLED irrespective of the bleeding definitions and so was the IDI analysis. The BARC 3 or 5 bleeding was significantly higher in the 24 month DAPT arm in the CRUSADE>40 (HR 2.69; p=0.043) but not in the CRUSADE≤40 group (HR 1.50; p=0.252) (pINT=0.334). In the prolonged DAPT arm, the number of patients needed to be treated for a major bleeding event in the high (>40) and low (≤40) CRUSADE score groups were 17, and 125, respectively. conclusion: Our analysis suggests that the CRUSADE score performs better in predicting major bleeding events in an all-comer population as compared to ACUITY and HAS-BLED. While no formal interaction was noted between bleeding risk status and bleeding outcomes with respect to the duration of DAPT, patients at high —but not those at low— bleeding risk showed a clear and significant increase in major bleeding in the long-term DAPT group. Prolonging DAPT up to 24 vs. 6 months in these patients would result in an extra bleeding every 17 treated patients as compared to 125 in those not at high bleeding risk.