The optimal duration of dual antiplatelet therapy (DAPT) following percutaneous coronary intervention depends on balancing the prevention of ischemic events against the risk of bleeding. Although abbreviated DAPT regimens have demonstrated benefits in patients at high bleeding risk, this population is heterogeneous and may exhibit substantial differences in both absolute bleeding risk and the potential benefit of early P2Y12 inhibitor discontinuation. The PRECISE-HBR score was developed to stratify patients into three categories: non-high, high, and very high bleeding risk.
The study presented by Cao et al. aimed to validate the ability of the PRECISE-HBR score to predict major bleeding and to assess its usefulness in identifying patients who may benefit from 1 month versus 3 months of DAPT after implantation of everolimus-eluting stents.
The analysis included patients enrolled in the XIENCE Short DAPT program. All patients had undergone successful percutaneous coronary intervention with cobalt-chromium everolimus-eluting stents and met at least one protocol-defined criterion for high bleeding risk.
Patients in the XIENCE 28 study discontinued the P2Y12 inhibitor after 1 month, whereas those enrolled in XIENCE 90 discontinued it after 3 months, subsequently continuing aspirin monotherapy. To be included in the analysis, patients had to be adherent to treatment and free from major adverse cardiovascular events (MACE), including myocardial infarction, stroke, stent thrombosis, or repeat revascularization, during the first month. Comparisons between groups were adjusted using propensity score stratification.
The PRECISE-HBR score was calculated using its alternative version, which incorporates age, hemoglobin level, renal function, myocardial infarction at presentation, prior spontaneous bleeding, chronic oral anticoagulation, and additional ARC-HBR criteria. Scores were classified as non-high risk (≤22), high risk (23–26), and very high risk (≥27). The primary endpoint was the composite of all-cause death or myocardial infarction between months 1 and 12. Major bleeding was defined as BARC type 3–5 bleeding.
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Among the 3,364 patients who were event-free at 1 month, 10.7% had a score ≤22, 22.1% had a score between 23 and 26, and 67.2% had a score ≥27. Patients in the very high-risk group were older and more frequently had chronic kidney disease, anemia, chronic oral anticoagulation, prior bleeding, and acute myocardial infarction at presentation.
The incidence of BARC 3–5 bleeding was 0.3%, 2.5%, and 5.6% in the non-high-, high-, and very high-risk groups, respectively. Likewise, the rate of death or myocardial infarction increased from 2.9% to 4.6% and 9.8%. Net adverse clinical events also increased progressively across risk categories, reaching 3.8%, 7.2%, and 14.5%, respectively.
The PRECISE-HBR score demonstrated moderate discrimination for predicting BARC 3–5 bleeding, with an area under the curve (AUC) of 0.68 (95% CI: 0.63–0.72), outperforming the PRECISE-DAPT score (AUC: 0.61). Its performance was comparable to the continuous ARC-HBR score (AUC: 0.68; p=0.97).
Among patients with a PRECISE-HBR score ≥27, 1 month of DAPT significantly reduced BARC 2–5 bleeding compared with 3 months of DAPT (adjusted HR: 0.65; 95% CI: 0.49–0.87), as well as major BARC 3–5 bleeding (adjusted HR: 0.59; 95% CI: 0.39–0.88). In this very high-risk subgroup, 1-month DAPT also reduced net adverse clinical events (adjusted HR: 0.74; 95% CI: 0.58–0.94), whereas no significant benefit was observed in patients with a score <27 (interaction p=0.048).
Conclusions: A PRECISE-HBR score ≥27 identifies patients who derive the greatest benefit from 1-month DAPT.
The PRECISE-HBR score identified a population with a progressive increase in both bleeding and ischemic risk. Among patients with a score ≥27, discontinuation of the P2Y12 inhibitor after 1 month was associated with lower rates of major bleeding and net adverse clinical events, without increasing the risk of death or myocardial infarction compared with 3 months of DAPT.
Original Title: Abbreviated DAPT Regimens Across the Entire Spectrum of Bleeding Risk According to the PRECISE-HBR Score.
Reference: Cao, D, Oliva, A, Mehran, R. et al. Abbreviated DAPT Regimens Across the Entire Spectrum of Bleeding Risk According to the PRECISE-HBR Score. J Am Coll Cardiol Intv. 2026 Jul, 19 (13) 1766–1777. https://doi.org/10.1016/j.jcin.2026.04.051.
