• Fabrizio D'Ascenzo, Ovidio De Filippo, Guglielmo Gallone, Gianluca Mittone, Marco Agostino Deriu, Mario Iannaccone, Albert Ariza-Solé, Christoph Liebetrau, Sergio Manzano-Fernández, Giorgio Quadri, Tim Kinnaird, Gianluca Campo, Jose Paulo Simao Henriques, James M Hughes, Alberto Dominguez-Rodriguez, Marco Aldinucci, Umberto Morbiducci, Giuseppe Patti, Sergio Raposeiras-Roubin, Emad Abu-Assi, Gaetano Maria De Ferrari, and PRAISE study group.
• Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, Turin, Italy; Cardiology, Department of Medical Sciences, University of Turin, Turin, Italy. Electronic address: fabrizio.dascenzo@gmail.com.
• Lancet. 2021 Jan 16; 397 (10270): 199-207.

BackgroundThe accuracy of current prediction tools for ischaemic and bleeding events after an acute coronary syndrome (ACS) remains insufficient for individualised patient management strategies. We developed a machine learning-based risk stratification model to predict all-cause death, recurrent acute myocardial infarction, and major bleeding after ACS.MethodsDifferent machine learning models for the prediction of 1-year post-discharge all-cause death, myocardial infarction, and major bleeding (defined as Bleeding Academic Research Consortium type 3 or 5) were trained on a cohort of 19 826 adult patients with ACS (split into a training cohort [80%] and internal validation cohort [20%]) from the BleeMACS and RENAMI registries, which included patients across several continents. 25 clinical features routinely assessed at discharge were used to inform the models. The best-performing model for each study outcome (the PRAISE score) was tested in an external validation cohort of 3444 patients with ACS pooled from a randomised controlled trial and three prospective registries. Model performance was assessed according to a range of learning metrics including area under the receiver operating characteristic curve (AUC).FindingsThe PRAISE score showed an AUC of 0·82 (95% CI 0·78-0·85) in the internal validation cohort and 0·92 (0·90-0·93) in the external validation cohort for 1-year all-cause death; an AUC of 0·74 (0·70-0·78) in the internal validation cohort and 0·81 (0·76-0·85) in the external validation cohort for 1-year myocardial infarction; and an AUC of 0·70 (0·66-0·75) in the internal validation cohort and 0·86 (0·82-0·89) in the external validation cohort for 1-year major bleeding.InterpretationA machine learning-based approach for the identification of predictors of events after an ACS is feasible and effective. The PRAISE score showed accurate discriminative capabilities for the prediction of all-cause death, myocardial infarction, and major bleeding, and might be useful to guide clinical decision making.FundingNone.Copyright © 2021 Elsevier Ltd. All rights reserved.

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