High Ischaemic Risk Criteria in Chronic Coronary Syndrome: Prevalence and Prognosis

Despite advances in the management of chronic coronary syndrome (CCS), including the widespread use of drug-eluting stents (DES) and the optimization of medical therapy, a proportion of patients undergoing percutaneous coronary intervention (PCI) continue to experience adverse events. Therefore, reducing residual ischaemic risk remains a key challenge in the management of CCS.

According to the 2024 European Society of Cardiology (ESC) guidelines, a default duration of 6 months of dual antiplatelet therapy (DAPT) is recommended after elective PCI; however, treatment should be tailored according to each patient’s bleeding and ischaemic risk profile. In patients with high ischaemic risk (HIR), strategies to intensify antithrombotic therapy may include prolonged DAPT or the combination of antiplatelet therapy with anticoagulation. 

While multiple bleeding risk scores are available to guide treatment decisions, standardized tools for ischaemic risk assessment remain limited and have not been systematically validated to guide decisions regarding prolonged antithrombotic therapy.

Thrombotic risk is influenced by anatomical, procedural, and clinical factors. As highlighted in the 2024 ESC guidelines, the main clinical risk factors include diabetes mellitus and chronic kidney disease (CKD); in addition, procedural characteristics that further increase ischaemic risk include the treatment of chronic total occlusions (CTO), bifurcation lesions requiring stent implantation in both the main vessel and side branches, total stent length >60 mm, and PCI of the left main coronary artery.

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The aim of this study was to evaluate the prevalence and prognostic impact of these criteria in a large cohort of patients undergoing PCI in routine clinical practice.

The Primary Endpoint (PE) was the rate of major adverse cardiovascular and cerebrovascular events (MACCE), defined as a composite of all-cause death, myocardial infarction (MI), and stroke at 1 year following PCI. The Secondary Endpoint (SE) included the individual components of the PE, target vessel revascularization, stent thrombosis, and bleeding events.

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Among 15,336 patients with CCS, 10,952 (71.4%) met at least one HIR criterion. Overall, HIR status and most of its individual components—except for bifurcation and CTO—predicted major adverse cardiovascular events (MACCE). A higher number of HIR criteria was significantly associated with a higher incidence of MACCE (p <0.001), as well as with the individual components of death (p <0.001) and MI (p <0.001).

Conclusion: Prognostic value of clinical and procedural factors to guide antithrombotic therapy in CCS patients undergoing PCI

In this large contemporary cohort of patients with CCS undergoing PCI, the ESC 2024 HIR criteria effectively identified those at higher risk of ischaemic events at 1 year. Our findings confirm the prognostic relevance of several clinical and anatomical factors, particularly diabetes, chronic kidney disease, left main coronary artery disease, and longer stent length, while highlighting the limited predictive value of certain procedural characteristics, such as bifurcation interventions and chronic total occlusions (CTO), in the current era of optimized PCI techniques.

Given the high prevalence of HIR features in real-world clinical practice and their partial overlap with bleeding risk factors, future efforts should focus on refining this classification into a more detailed and personalized system to better predict ischaemic risk.

Original Title: Prevalence and prognostic impact of high ischaemic risk criteria in chronic coronary syndrome patients undergoing PCI.

Reference: Valeria Raona et al EuroIntervention 2026;22:e392-e401.