Coronary interventions

Derivation and validation of the ISAR score to predict the risk of repeat percutaneous coronary intervention for recurrent drug-eluting stent restenosis

EuroIntervention 2023;18:e1328-e1338. DOI: 10.4244/EIJ-D-22-00860

JJ Coughlan
JJ Coughlan1, MD, MB, BCh; Alp Aytekin1, MD; Shqipdona Lahu1, MD; Maria Scalamogna1,2, MD; Jens Wiebe1, MD; Susanne Pinieck1, RN; Sebastian Kufner1, MD; Erion Xhepa1, MD, PhD; Michael Joner1,3, MD; Constantin Kuna1, MD; Felix Voll1, MD; Karl Ludwig Laugwitz3,4, MD; Heribert Schunkert1,3, MD; Adnan Kastrati1,3, MD; Salvatore Cassese1, MD, PhD
1. Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; 2. Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy; 3. DZHK (German Center for Cardiovascular Research), Partner site Munich Heart Alliance, Munich, Germany; 4. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany

Background: The treatment of drug-eluting stent (DES) in-stent restenosis (ISR) is challenging as it has a high risk of recurrence.

Aims: The aim of this analysis was to develop and validate a model to predict the risk of repeat percutaneous coronary intervention (PCI) for recurrent DES-ISR.

Methods: A retrospective, observational analysis was performed including consecutive patients treated with PCI for DES-ISR at two centres in Germany. Included patients were randomly divided into training and validation cohorts. Two regression analyses identified factors associated with repeat PCI for recurrent DES-ISR up to 1 year. The discriminative ability of the resultant model was then compared to a benchmark ISR classification model using bootstrap resampling. A classification and regression tree analysis and a numerical scoring system (the ISAR score) were used to predict the risk of repeat PCI for recurrent DES-ISR based on the identified predictors.

Results: We included 1,986 patients in the current analysis, divided randomly into training (1,471 patients, 1,778 lesions) and validation (515 patients, 614 lesions) cohorts. Four factor variables (a non-focal ISR pattern, a time interval to ISR of <6 months, ISR of the left circumflex artery and ISR in a calcified vessel) were associated with repeat PCI for recurrent DES-ISR at 1-year follow-up. On bootstrap resampling analysis, the C-statistic for the model including these four variables was 0.60 (95% confidence interval [CI]: 0.57-0.63), whereas the C-statistic for the benchmark ISR classification model was 0.54 (95% CI: 0.52-0.57), a difference that was statistically significant (delta C-statistic 0.062; 95% CI: 0.035-0.094; p<0.001). The cumulative incidence of repeat PCI for recurrent DES-ISR was over three times higher in DES-ISR lesions with an ISAR score of ≥3 in comparison to lesions with an ISAR score of 0.

Conclusions: This study developed and validated a risk prediction model for repeat PCI for recurrent DES-ISR at 1-year follow-up. This model served to generate the ISAR score, a standardised tool that can be used to predict the 1-year risk of repeat PCI for recurrent DES-ISR.

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