D-dimer levels enhance the discriminatory capacity of bleeding risk scores for predicting in-hospital bleeding events in acute pulmonary embolism

Abstract

IntroductionBleeding is a major complication of anticoagulation in acute pulmonary embolism (APE) while estimating individual bleeding risk remains challenging. Elevated D-dimer levels (DD) have been shown to predict bleeding events. Objectives(1) direct comparison of the capacity of bleeding risk prediction scores (VTE-BLEED, RIETE, HAS-BLED, HEMORR2HAGES) to prognosticate in-hospital bleeding events in the acute phase of APE in a real-life population of APE patients;(2) augmentation of the discriminative capacity of fore mentioned scores with DD. MaterialsPost-hoc analysis of a prospective observational study. DD levels were measured using the VIDAS D-dimer Exclusion test. Receiver operating characteristic curves, areas under the curve (AUC) for bleeding prediction were calculated for scores and DD. Bleeding scores+DD were compared using an established index quantifying the reclassification of patients (net reclassification index, NRI). Results310 APE patients were included. 35(11.3%) bleeding events occurred (hematomas, GI, urinary tract, retroperitoneal, uterine, CNS, respiratory tract): 17 major (MB) and 18 clinically-relevant non-major bleedings (CRNMB), none were fatal. All scores had satisfactory AUCs (0.754–0.767), except HAS-BLED (AUC = 0.512; 0.455–0.569). DD were higher in patients with bleeding events (29,911 ng/ml vs. 4805 ng/ml, p = .031), AUC 0.621(0.520–0.721), p = .02. DD = 5750 ng/ml was characterized by OR = 2.3(95%CI 1.05–5.0) for all bleeding events. Adding DD improved the discriminatory capacity of tested scores in the non-high risk of bleeding category, NRI 0.07–03. ConclusionsOf the tested scores RIETE, HEMORR2HAGES, VTE-BLEED performed best at identifying APE patients at risk of in-hospital bleeding complications. DD levels may predict in-hospital bleeding events and may improve identifying patients classified as non-high risk who experience bleeding complications.