Giuseppe Biondi Zoccai, MD University of Modena and Reggio Emilia gbiondizoccai@gmail

1. Improving clinical risk prediction for percutaneous coronary intervention for bifurcation lesions: the ACEF (age, creatinine, ejection fraction) score Giuseppe Biondi Zoccai, MD University of Modena and Reggio Emilia gbiondizoccai@gmail.com

2. BACKGROUND • Coronary bifurcations are among the most challenging lesions for percutaneous coronary intervention (PCI). • There is no simple and effective tool to identify patients with a good prognosis despite such complex coronary disease. • A novel and user-friendly risk score, the ACEF (age, creatinine, ejection fraction) has been proved effective in unselected patients undergoing cardiac surgery. • However, limited data are available in patients undergoing PCI.

3. GOAL • We aimed to appraise the predictive accuracy of the ACEF in patients undergoing PCI for coronary bifurcations.

4. METHODS • A multicenter, retrospective study was conducted enrolling consecutive patients undergoing bifurcation PCI between January 2002 and December 2006 in 22 Italian centers. • Patients with complete data to enable computation of the ACEF score (defined as age [years]/ejection fraction [%]+1 [if serum creatinine value was >2.0 mg/dL) were divided in 3 groups according to tertiles of ACEF score.

5. METHODS • The primary end-point was the long-term rate of all cause mortality. • Additional end-points including early and long-term rates of all cause death, cardiac death, myocardial infarction (MI), major adverse cardiac events (MACE, i.e. Death, MI or revascularization), and stent thrombosis. • The discrimination of the ACEF score as a continuous variable was also appraised with area under the curve (AUC) of the receiver-operating characteristic.

6. RESULTS • A total of 3,535 patients were included: 1119 in the lowest quartile of ACEF score, 1190 in the 2nd quartile, and 1153 in the highest quartile. • Increased ACEF score was associated with significantly different rates of early all cause death (0.1% in the 1st quartile vs 0.5% in the 2nd quartile and 3.0% in the 3rd quartile, p<0.001), with similar differences in MI (0.3% vs 0.7% and 1.8%, p<0.001) and major adverse cardiac events (MACE, 0.5% vs 1.2% and 4.3%, p<0.001).

7. RESULTS • After 24.4±15.1 months, increased ACEF score was still associated with a higher rate of all cause death (1.3% vs 2.4% and 11.0%, p<0.001), cardiac death (0.9% vs 1.4% and 7.2%, p<0.001), MI (3.4% vs 2.7% and 5.7%, p<0.001), MACE (13.6% vs 15.9% and 22.3%, p<0.001), and stent thrombosis (2.3% vs 1.8% and 5.0%, p<0.001).

8. RESULTS • Discrimination of ACEF score was good for early all cause death (AUC=0.82 [0.77-0.87]), early MACE (AUC=0.73 [0.67-0.78]), long-term all cause death (AUC=0.76 [0.72-0.79]) and long-term cardiac death (AUC=0.76 [0.72-0.81]). • Conversely, it appeared modest for long-term MACE (AUC=0.58 [0.55-0.60]).

9. BASELINE FEATURES

10. LESION/PROCEDURAL DATA

11. EARLY OUTCOMES

12. LONG-TERM OUTCOMES

13. EARLY DEATH Area under the curve=0.82 (0.77-0.87), p<0.001

14. EARLY MACE Area under the curve=0.73 (0.67-0.78), p<0.001

15. LONG TERM DEATH Area under the curve=0.79 (0.72-0.79), p<0.001

16. LONG TERM CARDIAC DEATH Area under the curve=0.76 (0.72-0.81), p<0.001

17. LONG TERM MACE Area under the curve=0.58 (0.55-0.60), p<0.001

18. CONCLUSIONS • The simple and user-friendly ACEF score can accurately identify patients undergoing PCI for coronary bifurcation lesions at high risk of early fatal or non-fatal complications, as well as long-term fatality. • Its role in comparison to more complex and sophisticated predictions tools (e.g. the SYNTAX score) warrants further investigations.

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