In our study, we present several findings regarding the prognostic role of the PRECISE-DAPT score in an unselected ACS population:

1.

The PRECISE-DAPT score threshold ≥ 25 has the potential to predict outcome in mid-term follow-up of 1.9 years, with the best predictive ability in STEMI.

2.

Revascularization strategy (PCI vs. CABG) does not significantly influence the prognostic role of PRECISE-DAPT score in ACS.

3.

The PRECISE-DAPT score maintains acceptable prognostic performance regardless of antithrombotic treatment strategy at discharge.

In 2017, the PREdicting bleeding Complications in patients undergoing stent Implantation and SubsequEnt Dual AntiPlatelet Therapy (PRECISE DAPT) score was proposed and its popularity in the following years quickly increased. This simple yet effective model has proved its ability to help guide the duration of antiplatelet treatment after PCI [1, 2]. Several recent studies have validated the use of the PRECISE-DAPT score in patients with ACS [4, 5, 7, 8]. Originally, the PRECISE-DAPT score of ≥ 25 indicated high bleeding risk (HBR). It has been documented that STEMI patients treated by PCI and subsequent DAPT with a PRECISE-DAPT score ≥ 25 have significantly higher in-hospital mortality [15]. Similarly, our results show significant in-hospital (1.1% vs. 11.6%) and mid-term (10.0% vs. 42.5%) mortality differences between the PRECISE-DAPT score groups. The reliability of threshold 25 is supported by the apparent differences between the groups. Patients with PRECISE_DAPT score ≥ 25 were over 15 years older, had more complex coronary disease, additional comorbidities, and were in higher KILLIP class at admission. All these aspects influence a reported worse outcome compared to patients in the lower PRECISE-DAPT score group.

First, we have demonstrated that a threshold ≥ 25 can effectively predict mid-term prognosis in unselected patients with ACS. Recently, similar results were presented by Ando et al. There were 552 patients with myocardial infarction treated by PCI with a mean follow-up of 1424 days. The PRECISE-DAPT score predicted mortality with an AUC of 0.78 [7]. In comparison, our study proved a better discrimination value for STEMI, suggesting a more appropriate ACS subgroup for prognostication by the PRECISE-DAPT score. We hypothesize that these results highlight bleeding as one of the prominent risk factors in STEMI patients, the youngest group with the least comorbidities.

Second, the prognostic role of the PRECISE-DAPT score did not change according to revascularization strategy (PCI vs. CABG). Enström et al. investigated bleeding complications after CABG with the same threshold of ≥ 25. The authors concluded that the PRECISE-DAPT score of 25 can be used for prognostication purposes in CABG patients, regardless of different antithrombotic strategies [6]. Although both strategies pose different risks during initial hospitalization, the influence of the revascularization strategy on bleeding diminishes in the long term.

Finally, we evaluated the performance of the PRECISE-DAPT threshold ≥ 25 in different antithrombotic strategies at discharge and to our knowledge, it has been investigated for the first time. We found a significant difference in DAPT and DAT, but not TAT, recommendations at discharge according to the PRECISE-DAPT score. When correlated with mid-term outcome, there were no significant differences among the three different treatment strategies—DAPT, DAT and TAT (all AUCs between 0.7 and 0.8). Moreover, the predictive ability of PRECISE-DAPT score for patients with combined antithrombotic strategies was almost identical (DAT vs. TAT, AUC 0.71 vs. AUC 0.72, respectively). These results are somewhat surprising, considering the higher incidence of atrial fibrillation among older patients, which is reflected in the final PRECISE-DAPT score [16]. In our analyses, these two strategies seemingly do not differ in the occurrence of fatal (bleeding and/or ischemic) complications. We should, however, interpret these results with caution as a limited number of patients with a specific combination of antithrombotic agents were analyzed and the duration of antithrombotic treatment could have changed after discharge. Nevertheless, the PRECISE-DAPT score showed acceptable mid-term performance regardless of antithrombotic strategy at discharge. We hypothesize that patient selection and recommended duration of antithrombotic treatment play a key role in avoiding fatal bleeding and/or ischemic complications. Results of our retrospective analysis, although on a limited number of patients, suggest that with a personalized antithrombotic strategy, the PRECISE-DAPT score with a threshold ≥ 25 can be used as a universal prognostic tool for mid-term mortality in ACS.