The Combined Predictive Value of the GRACE Score and the ARC-HBR Criteria for Bleeding Risk After Percutaneous Coronary Intervention in STEMI Patients

Xiaoying Wang,1,* Yuanyuan Ning,2,* Xiaojuan Wang,1 Guangli Li,1 Dong Wu,1 Xiaowu Wang,3 Zhen Huang4 1Department of Pharmacy, Fuyang People’s Hospital, Fuyang, Anhui, 236000, People’s Republic of China; 2Department of Clinical Laboratory, the First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, 241000, People’s Republic of China; 3Department of Clinical Laboratory, The Second People’s Hospital of Fuyang, Fuyang Infection Disease Clinical College of Anhui Medical University, Fuyang, Anhui, 236000, People’s Republic of China; 4Department of Scientific Research, Fuyang People’s Hospital, Fuyang, Anhui, 236000, People’s Republic of China*These authors contributed equally to this workCorrespondence: Xiaowu Wang, Department of Clinical Laboratory, The Second People’s Hospital of Fuyang, Fuyang infection Disease Clinical College of Anhui Medical University, Fuyang, Anhui, 236000, People’s Republic of China, Email wangxiaowu19880218@126.com Zhen Huang, Department of Scientific Research, Fuyang People’s Hospital, Fuyang, Anhui, 236000, People’s Republic of China, Email huangzhenfy@163.comObjective: To evaluate the incremental predictive value of the Global Registry of Acute Coronary Events (GRACE) score combined with the Academic Research Consortium for High Bleeding Risk (ARC-HBR) criteria for bleeding risk after percutaneous coronary intervention (PCI) in patients with ST‑segment elevation myocardial infarction (STEMI).Methods: This prospective observational study enrolled 338 STEMI patients who underwent their first PCI at Fuyang People’s Hospital from January 2023 to March 2024. Bleeding events were defined according to the Bleeding Academic Research Consortium (BARC) types 1– 5. Patients were stratified by GRACE score (low/middle/high) and ARC‑HBR status (high/low). The predictive performance of the model was assessed using receiver operating characteristic (ROC) curves, net reclassification improvement (NRI), integrated discrimination improvement (IDI), decision curve analysis (DCA), and calibration plots. Internal validation was performed via bootstrap resampling (1,000 iterations).Results: Bleeding occurred in 83 patients (24.56%), with 63 in‑hospital events (18.64%) and 34 out‑of‑hospital events (10.06%). The majority were mild (BARC type 1, 82.54% in‑hospital; 73.53% out‑of‑hospital). The combined GRACE + ARC‑HBR model achieved an area under the ROC curve (AUC) of 0.774 (95% CI 0.726– 0.818), compared with 0.712 (95% CI 0.660– 0.759) for GRACE alone and 0.667 (95% CI 0.614– 0.717) for ARC‑HBR alone. Versus GRACE, the combined model showed a non‑significant NRI (− 0.0509; P = 0.0945) but a significant IDI (0.0560; P = 0.0006). Versus ARC‑HBR, both NRI (0.3277; P = 0.0007) and IDI (0.0768; P < 0.0001) were significantly positive. DCA demonstrated the highest net benefit for the combined model across most threshold probabilities. The calibration curve yielded a Brier score of 0.147, and the Hosmer-Lemeshow test confirmed good calibration (χ2=3.568, P=0.8938). Bootstrap internal validation produced a bias‑corrected AUC of 0.775.Conclusion: Compared with either score alone, the combination of the GRACE score and the ARC-HBR criteria provides incremental predictive value for post-PCI bleeding in STEMI patients.Keywords: acute ST-elevation myocardial infarction, percutaneous coronary intervention, bleeding, GRACE score, ARC-HBR criteria