Refining risk in cancer patients with coronary artery disease: do ARC-HBR criteria deliver?
C Silva, D Ferreira, D Cazeiro, J Cravo, M Vilela, T Rodrigues, A R Francisco, J Marques, C Jorge, P Carrilho, J Duarte, J Marques da Costa, P Cardoso, M Menezes, F J PintoAbstract
Introduction
Cancer patients frequently present with complex coronary disease and elevated ischemic and bleeding risks. The ARC-HBR criteria were developed to identify patients at high bleeding risk, but their performance in cardio-oncology populations remains insufficiently characterized. This study evaluated the ability of ARC-HBR to predict major bleeding in cancer patients with severe coronary disease treated across different revascularization strategies.
Methods
We conducted a retrospective study of 150 consecutive cancer patients from 2017 to 2023 with severe coronary disease who underwent PCI, CABG, or, when revascularization was not feasible, were treated with DAPT or single antiplatelet therapy plus anticoagulation for at least 6 months. ARC-HBR status was determined according to the original definition. Baseline characteristics, angiographic data, and clinical outcomes were compared between ARC-HBR and non–ARC-HBR patients. Major bleeding was defined as BARC type 3 or 5. Logistic regression assessed associations with major bleeding and mortality. Mean follow-up was 3.4 years.
Results
Ninety-nine patients (66%) met ARC-HBR criteria and 51 (34%) were classified as non–ARC-HBR. Baseline cardiovascular risk factors and angiographic characteristics were generally comparable between groups. Age tended to be higher in ARC-HBR patients, and chronic kidney disease was markedly more prevalent (62% vs 26%, p<0.001). Hemoglobin and platelet levels were lower in ARC-HBR patients, though without statistical significance. As expected, active malignancy occurred exclusively in the ARC-HBR group, as it constitutes a major criterion.
Major bleeding occurred in 15 patients (10%), with substantially higher rates in ARC-HBR compared with non–ARC-HBR patients (14% vs 2%, p=0.018). In ARC-HBR patients, the 3.4-year mean follow-up corresponds to an annualized major bleeding rate of 4.1 events per 100 patient-years, closely matching the ≥4% 1-year risk threshold that defines ARC-HBR. ARC-HBR status was associated with an eight-fold increase in major bleeding risk (OR 8.24, p=0.045) and a significant rise in mortality (OR 5.08, p<0.001).
Conclusion
In cancer patients with severe coronary disease, ARC-HBR status effectively identified individuals at substantially higher risk of major bleeding and mortality, supporting its applicability and internal validity in this cardio-oncology population.ACR-HBR