Bleeding Risk Scores In Patients Research Articles

Antiplatelet Therapy for Elderly Patients with Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention.

The elderly represent an increasing proportion of patients presenting with acute coronary syndrome (ACS). Various data have shown that the benefits of percutaneous coronary revascularization are maintained in elderly patients presenting with ACS. Conversely, the management of antiplatelet therapy remains challenging and controversial, because older patients are usually at a high risk of both ischemia and bleeding. Moreover, the recommended ischemic and bleeding risk scores in patients with ACS were developed from studies with a low representation of older patients. New antiplatelet strategies have been developed, but their evidence in elderly patients is limited because they are usually underrepresented in randomized clinical trials due to their clinical complexity. The aim of this review is to summarize the different factors associated with increased ischemic and/or bleeding risk and the scientific evidence about the different antiplatelet strategies in elderly patients presenting with ACS and undergoing percutaneous coronary revascularization.

Predicting performance of the HAS-BLED and ORBIT bleeding risk scores in patients with atrial fibrillation treated with Rivaroxaban: Observations from the prospective EMIR Registry.

Assessing bleeding risk during the decision-making process of starting oral anticoagulation (OAC) therapy in atrial fibrillation (AF) patients is essential. Several bleeding risk scores have been proposed for vitamin K antagonist users but, few studies have focused on validation of these bleeding risk scores in patients taking direct oral anticoagulants (DOACs). The aim was to compare the predictive ability of HAS-BLED and ORBIT bleeding risk scores in AF patients taking rivaroxaban in the EMIR ('Estudio observacional para la identificación de los factores de riesgo asociados a eventos cardiovasculares mayores en pacientes con fibrilación auricular no valvular tratados con un anticoagulante oral directo [Rivaroxaban]) Study. EMIR Study was an observational, multicenter, post-authorization, and prospective study that involved AF patients under OAC with rivaroxaban at least 6 months before enrolment. We analysed baseline clinical characteristics and adverse events after 2.5 years of follow-up and validated the predictive ability of HAS-BLED and ORBIT scores for major bleeding (MB) events.We analysed 1433 patients with mean age of 74.2±9.7 (44.5% female). Mean HAS-BLED score was 1.6±1.0 and ORBIT score was 1.1±1.2. The ORBIT score categorised a higher proportion of patients as 'low-risk' (87.1%) compared with 53.5% using the HAS-BLED score. There were 33 MB events (1.04%/year) and 87 patients died (2.73%/year). Both HAS-BLED and ORBIT had a good predictive ability for MB{Area under the curve (AUC) 0.770, [95% confidence interval (CI) 0.693-0.847; P<0.001] and AUC 0.765 (95% CI 0.672-0.858; P<0.001), respectively}. There was a non-significant difference for discriminative ability of the two tested scores (P=0.930) and risk reclassification in terms of net reclassification improvement (NRI) -5.7 (95% CI -42.4-31.1; P=0.762). HAS-BLED score showed the best calibration and ORBIT score showed the largest mismatch in calibration, particularly in higher predicted risk patients. In a prospective real-world AF population under rivaroxaban from EMIR registry, the HAS-BLED score had good predictive performance and calibration compared with ORBIT score for MB events. ORBIT score presented worse calibration than HAS-BLED in this DOAC treated population.

Validation of Embolic and Bleeding Risk Scores in Patients With Atrial Fibrillation and Cancer

Little is known about the prediction of atrial fibrillation (AF) risk scores in patients with cancer. The aim of this study was to assess the predictive ability of the CHA₂DS₂-VASc and HAS-BLED scores in patients with AF and cancer. Overall, 16,056 patients with AF diagnosed between 2014 and 2018 from a Spanish health area, including 1,137 patients with cancer, were observed during a median follow-up of 4.9years. Although discrimination was similar between patients with cancer and patients without cancer who were treated with anticoagulation therapy (0.56 and 0.58), in patients with cancer who were not treated with anticoagulation therapy, c-statistic of CHA₂DS₂-VASc was poor and significantly lower than in the patients without cancer (0.42 vs 0.65). The overall precision of the CHA₂DS₂-VASc score was good throughout the follow-up (Brier score &lt; 0.1), in patients with and without cancer. Regarding the HAS-BLED score, calibration and discrimination were poor in patients with cancer (c-statistic 0.51), similar to those in patients without cancer (c-statistic 0.53). In patients with cancer who were not treated with anticoagulation therapy, the embolic risk CHA₂DS₂-VASc score=1 was similar to CHA₂DS₂-VASc score ≥ 2. Only patients with AF and cancer and CHA₂DS₂-VASc score=0 presented a low risk of embolic events (negative predictive value 100%). A HAS-BLED score &gt; 3 was not associated with higher bleeding risk in patients with cancer (p &gt; 0.05). In summary, in patients with cancer and with AF, neither the CHA₂DS₂-VASc score nor the HAS-BLED score was useful for predicting embolic and hemorrhagic events, respectively. However, a CHA₂DS₂-VASc score 0 is useful to identify patients with AF and cancer who are at low embolic risk.

Validation of Embolic and Bleeding Risk Scores in Patients with Atrial Fibrillation and Cancer

Validation of Embolic and Bleeding Risk Scores in Patients with Atrial Fibrillation and Cancer

Predictive performance of different bleeding risk scores in patients with atrial fibrillation and acute coronary syndrome or undergoing percutaneous coronary intervention

This study aims to evaluate the predictive values of the HAS-BLED, ORBIT, ATRIA, REACH, PARIS, and PRECISE-DAPT scores in patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI) who received both anticoagulant and antiplatelet therapy. 930 patients were consecutively recruited and followed up for 1 year. The primary endpoints were BARC class ≥3 bleeding and BARC class ≥2 bleeding. BARC class ≥3 bleeding occurred in 36 patients(3.9%), while BARC class ≥2 bleeding was seen in 134 patients (14.4%). The predictive performance of the HAS-BLED score for BARC class ≥3 bleeding was unsatisfactory (c-statistic = 0.575). The discrimination of the ATRIA, ORBIT, PARIS, and PRECISE-DAPT scores was also low-to-moderate. The REACH score was useless in bleeding risk stratification for this population. Multivariable logistic regression indicated that previous bleeding events and hemoglobin were two independent predictors of BARC class ≥3 bleeding. Compared to the HAS-BLED score, the model constructed by previous bleeding events and hemoglobin displayed a significant improvement in bleeding risk prediction [c-statistics: 0.704 vs. 0.575 (p = .008), NRI = 0.662,IDI = 0.049]. In patients with AF and ACS or undergoing PCI who received anticoagulant+antiplatelet therapy, the HAS-BLED, ORBIT, ATRIA, REACH, PARIS, and PRECISE-DAPT scores displayed only low-to-moderate performance in predicting BARC class≥3 bleeding. Future studies are required to develop more reliable scoring systems for bleeding risk evaluation in this population.

Abstract 10623: Validation of Embolic and Bleeding Risk Scores in Patients with Atrial Fibrillation and Cancer

Introduction: Atrial fibrillation (AF) is common among cancer patients. Anticoagulation can reduce the risk of stroke and systemic embolism in AF patients. However, anticoagulation in patients with cancer can be difficult given unpredictable changes in thrombosis and bleeding risk. Although CHA 2 DS 2 -VASc and HAS-BLED are useful, their predictive performance in patients with cancer is unknown. Hypothesis: CHA 2 DS 2 -VASc and HAS-BLED scores in AF patients with cancer could lead to misclassification. Methods: Overall, 16,056 AF patients between 2014 and 2018 were followed during a median follow-up of 4.9 years, including 1,137 with cancer history. We used C statistic and Brier score for assessing the performance of both scores. Results: Discrimination, assessed with C statistics (assuming death as a competing risk), was similar between cancer and non-cancer anticoagulated patients. However, in non-anticoagulated patients, c-statistic of CHA 2 DS 2 -VASc was poor and significantly lower in non-cancer patients. The overall precision of the CHA 2 DS 2 -VASc score was good throughout the follow-up (Brier score &lt;0.1), both in patients with and without cancer history. Regarding to HAS-BLED score, calibration and discrimination were poor in cancer patients, although without significant differences in comparison with non-cancer patients. In non-anticoagulated cancer patients and in those with active cancer, the embolic risk of CHA 2 DS 2 -VASc score = 1 was similar to CHA 2 DS 2 -VASc score ≥ 2. Only AF patients with cancer and CHA 2 DS 2 -VASc score = 0 presented a truly low risk of embolic events (negative predictive value 100%). A HAS-BLED score &gt; 3 did not identify AF patients with cancer at higher bleeding risk. Conclusions: In AF patients with cancer, neither the CHA2DS2-VASC score nor the HASBLED score were useful for predicting embolic and hemorrhagic events, respectively. However, a CHA 2 DS 2 -VASc score 0 is useful to identify low embolic risk patients with AF and cancer.

Predictive performance of different bleeding risk scores in patients with atrial fibrillation and acute coronary syndrome or undergoing percutaneous coronary intervention

Abstract Background Standard scoring system for bleeding risk assessment has not been developed in patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI). The study aims to evaluate the predictive value of the HAS-BLED, ORBIT, ARTIA, PARIS, and PRECISE-DEAPT score in patients with AF and ACS/PCI who received both anticoagulant and antiplatelet therapy. Methods A total of 930 patients with AF and ACS/PCI receiving both anticoagulant and antiplatelet therapy were consecutively recruited and followed up for 1 year. The primary endpoint was defined according to the bleeding academic research consortium (BARC) criteria as major (BARC 3a, 3b, 3c, and 5) and any bleeding (BARC 2, 3a, 3b, 3c, and 5). The secondary endpoints included major or minor bleeding according to TIMI criteria. Univariate and multivariate logistic regression were performed to evaluate the association between bleeding risk scores and outcomes. Receiver operating characteristic (ROC) curves were constructed and c-statistics were calculated to evaluate the predictive performance of different bleeding risk scores. Results BARC class ≥2 bleedings occurred in 36 patients (3.9%), while BARC class ≥3 bleedings were seen in 134 patients (14.4%). The HAS-BLED, ORBIT, ARTIA, PARIS, and PRECISE-DEAPT score were significantly associated with incidences of BARC class ≥2 and ≥3 bleedings during 1-year follow-up (all p&amp;lt;0.05). The ROC analysis showed that the predictive performance of the five bleeding risk scores for BARC class ≥3 bleedings were low-to-moderate [c-statistic: HASBLED 0.584 (0.552–0.616), ATRIA 0.624 (0.592–0.655), ORBIT 0.623 (0.591–0.654), PARIS 0.633 (0.601–0.664), PRECISEDAPT 0.616 (0.584–0.647)]. Multivariable logistic regression indicated that previous bleeding history and hemoglobin were independent predictors of BARC class ≥3 bleedings. Compared to the HAS-BLED score, the model constructed by previous bleeding history and hemoglobin displays a significant improvement in bleeding risk prediction (0.704 vs. 0.584, p=0.013). Conclusions In patients with AF and ACS/PCI receiving both anticoagulant and antiplatelet therapy, the HAS-BLED, ORBIT, ARTIA, PARIS, and PRECISE-DEAPT score displayed low-to-moderate performance for predicting BARC class ≥3 bleedings during 1-year follow-up. More accurate scoring systems for bleeding risk evaluation should be developed for these patients in the future. Funding Acknowledgement Type of funding sources: None. Receiver operating characteristic curve

Prediction of Major Bleeding in Anticoagulated Patients for Venous Thromboembolism: Comparison of the RIETE and the VTE-BLEED Scores

The performance of validated bleeding risk scores in patients with venous thromboembolism (VTE) could be different depending on the time after index event or the site of bleeding. In this study we compared the “classic” Registro Informatizado de Enfermedad TromboEmbólica (RIETE) score and the more recently developed VTE-BLEED score for the prediction of major bleeding in patients under anticoagulant therapy in different time intervals after VTE diagnosis. Out of 82,239 patients with acute VTE, the proportion of high-risk patients according to the RIETE and VTE-BLEED scores was 7.1 and 62.3%, respectively. The performance of both scores across the different study periods (first 30 days after VTE diagnosis, days 31–90, days 91–180, and days 181–360) was similar, with areas under the receiving operating characteristics (ROC) curve (AUC) ranging between 0.69 and 0.72. However, the positive predictive values were low, ranging between 0.6 and 3.9 (better for early major bleeding than for later periods). A sensitivity analysis limited to patients with unprovoked VTE showed comparable results. Both scores showed a trend toward a better prediction of extracranial than intracranial major bleeding, the RIETE score resulting more useful for early extracranial bleeding and the VTE-BLEED for late intracranial hemorrhages. Our study reveals that the usefulness of available bleeding scores may vary depending on the characteristics of the patient population and the time frame evaluated. Dynamic scores could be more useful for this purpose.

Comparison of bleeding risk scores in patients with atrial fibrillation and cancer

Abstract Funding Acknowledgements Type of funding sources: None. Background. Cancer may increase bleeding risk in atrial fibrillation (AF), but the association between cancer type and specific bleeding events has been scarcely investigated. Furthermore, the performance of bleeding risk scores in this high-risk subgroup of patients is unclear. Purpose. To describe the incidence rate (IR) of major (MB), gastrointestinal (GI) bleeding and intracranial haemorrhage (ICH) according to cancer types. We also investigated the performance of HAS-BLED, ATRIA and ORBIT scores. Methods Observational retrospective cohort study including 399,344 patients with AF and cancer. Results. Mean age was 77.9 ± 10.2 years and 63.2% were men. During 2.0 years follow-up, the IR of MB was as high as 8.41%/y, GI bleeding was 3.61%/y and ICH 1.33%/y. MBs were more frequent in liver (12.68%/y), leukaemia (12.39%/y), pancreas (11.71%/y), bladder (11.67%/y) and myeloma (11.64%/y). GI bleedings were highest in liver (7.54%/y), pancreas (7.42%/y) and gastric (5.51%/y). ICH was highest in leukaemia (1.89%/y), myeloma (1.52%/y), lymphoma/liver (1.45%/y) and pancreas (1.41%/y) cancer. The Table shows the hazard ratio and AUC values for each bleeding score. All the three scores significantly associated with bleeding outcomes, with the HAS-BLED score performing better than others for ICH prediction, and the ORBIT score predicting MB and GI bleedings (p &amp;lt; 0.0001 for all AUC comparisons). Conclusions. Cancer increases the risk of bleeding in patients with cancer, with specific differences according to each cancer type. HAS-BLED score showed the best predictive value for ICH and the ORBIT score for MB and GI bleeding. MB GI bleeding ICH Hazard Ratio (95%CI) HASBLED score≥3 6.575 (6.390-6.765) 5.735 (5.502-5.978) 5.803 (5.416-6.218) ATRIA score≥5 5.372 (5.241-5.506) 3.617 (3.499-3.739) 1.469 (1.403-1.538) ORBIT score≥4 13.326 (12.977-13.686) 7.453 (7.202-7.712) 2.578 (2.463-2.699) AUC (95%CI) HASBLED score≥3 0.716 (0.714-0.718) 0.702 (0.699-0.704) 0.698 (0.694-0.702) ATRIA score≥5 0.700 (0.698-0.702) 0.662 (0.659-0.665) 0.563 (0.557-0.568) ORBIT score≥4 0.805 (0.804-0.807) 0.756 (0.753-0.758) 0.641 (0.635-0.646) AUC Difference (95% CI) HASBLED≥3 vs ATRIA≥5 0.016 (0.014-0.018) 0.040 (0.037-0.042) 0.136 (0.133-0.138) HASBLED≥3 vs ORBIT≥4 -0.089 (-0.091–0.087) -0.054 (-0.056–0.052) 0.057 (0.055-0.059) ATRIA≥5 vsORBIT≥4 -0.106 (-0.108–0.104) -0.094 (-0.095–0.092) -0.078 (-0.080–0.076)

The development and validation of a multivariable model to predict the bleeding risk score for patients with non-valvular atrial fibrillation using direct oral anticoagulants in the Arab population.

BackgroundFrequently used models, such as the HAS-BLED, ATRIA, ORBIT, and GARFIELD-AF evaluate the risk of bleeding when using an anticoagulant, for example warfarin, in patients with non-valvular atrial fibrillation. Limited studies are available reporting a model with a good discriminative ability to predict the bleeding risk score when using direct oral anticoagulants.MethodsPatient data were collected from King Abdulaziz Medical City, King Fahad Cardiac Center, and Prince Sultan Cardiac Center in Riyadh, from outpatients, inpatients, or primary care clinics. In total, 1722 patients with a prescription for a new oral anticoagulant, Dabigatran, Rivaroxaban, or Apixaban, were enrolled. A resampling approach for variable selection was used and a five-fold cross-validation to assess the model fit and misclassification probabilities. The analysis used the receiver operating characteristics curve (ROC) and the concordance (c) statistic to assess the validation models’ discriminative power. The final penalized likelihood parameters were used for the development of the risk prediction tool. The accuracy of a classification and the prediction are reported with the sensitivity, specificity, and Brier score.ResultsBleeding occurred in 11.15% of cases, of which 23.08% required a blood transfusion and 51.65% had a reduction in haemoglobin of more than 2 gm. The variable selection model identified 15 predictors associated with major bleeding. The discriminative ability of the model was good (c-statistic 0.75, p = 0.035). The Brier score of the model was 0.095. With a fixed cut-off probability value of 0.12 for the logistic regression equation, the sensitivity was 72.7%, and the specificity 66.3%.ConclusionThis model demonstrated a good performance in predicting the bleeding risk in Arab patients treated with novel oral anticoagulants. This easy to use bleeding risk score will allow the clinician to quickly classify patients according to their risk category, supporting close monitoring and follow-up for high-risk patients, without laboratory and radiological monitoring.

Novel bleeding risk score for patients with atrial fibrillation on oral anticoagulants, including direct oral anticoagulants

ObjectiveBalancing bleeding risk and stroke risk in patients with atrial fibrillation (AF) is a common challenge. Though several bleeding risk scores exist, most have not included patients on direct oral anticoagulants (DOACs). We aimed at developing a novel bleeding risk score for patients with AF on oral anticoagulants (OAC) including both vitamin K antagonists (VKA) and DOACs. MethodsWe included patients with AF on OACs from a prospective multicenter cohort study in Switzerland (SWISS‐AF). The outcome was time to first bleeding. Bleeding events were defined as major or clinically relevant non‐major bleeding. We used backward elimination to identify bleeding risk variables. We derived the score using a point score system based on the β‐coefficients from the multivariable model. We used the Brier score for model calibration (<0.25 indicating good calibration), and Harrel's c‐statistics for model discrimination. ResultsWe included 2147 patients with AF on OAC (72.5% male, mean age 73.4 ± 8.2 years), of whom 1209 (56.3%) took DOACs. After a follow‐up of 4.4 years, a total of 255 (11.9%) bleeding events occurred. After backward elimination, age > 75 years, history of cancer, prior major hemorrhage, and arterial hypertension remained in the final prediction model. The Brier score was 0.23 (95% confidence interval [CI] 0.19–0.27), the c‐statistic at 12 months was 0.71 (95% CI 0.63–0.80). ConclusionIn this prospective cohort study of AF patients and predominantly DOAC users, we successfully derived a bleeding risk prediction model with good calibration and discrimination.

Considerations when choosing an appropriate bleeding risk assessment tool for patients with atrial fibrillation

Considerations when choosing an appropriate bleeding risk assessment tool for patients with atrial fibrillation

Development and Validation of a Novel Risk Score for In-Hospital Major Bleeding in Acute Myocardial Infarction:-The SWEDEHEART Score.

BackgroundBleeding risk stratification in acute coronary syndrome is of highest clinical interest but current risk scores have limitations. We sought to develop and validate a new in‐hospital bleeding risk score for patients with acute myocardial infarction.Methods and ResultsFrom the nationwide SWEDEHEART (Swedish Web‐System for Enhancement and Development of Evidence‐Based Care in Heart Disease Evaluated According to Recommended Therapies) register, 97,597 patients with acute myocardial infarction enrolled from 2009 until 2014 were selected. A full model with 23 predictor variables and 8 interaction terms was fitted using logistic regression. The full model was approximated by a model with 5 predictors and 1 interaction term. Calibration, discrimination, and clinical utility was evaluated and compared with the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) and CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) scores. Internal and temporal validity was assessed. In‐hospital major bleeding, defined as fatal, intracranial, or requiring surgery or blood transfusion, occurred in 1356 patients (1.4%). The 5 predictors in the approximate model that constituted the SWEDEHEART score were hemoglobin, age, sex, creatinine, and C‐reactive protein. The ACTION and CRUSADE scores were poorly calibrated in the derivation cohort and therefore were recalibrated. The SWEDEHEART score showed higher discriminative ability than both recalibrated scores, overall (C‐index 0.80 versus 0.73/0.72) and in all predefined subgroups. Decision curve analysis demonstrated consistently positive and higher net benefit for the SWEDEHEART score compared with both recalibrated scores across all clinically relevant decision thresholds. The original ACTION and CRUSADE scores showed negative net benefit.ConclusionsThe 5‐item SWEDEHEART score discriminates in‐hospital major bleeding in patients with acute myocardial infarction and has superior model performance compared with the recalibrated ACTION and CRUSADE scores.

New score for assessing bleeding risk in patients with atrial fibrillation treated with NOACs

BackgroundInformation is needed on bleeding risk factors specific for patients with atrial fibrillation (AF) treated with non-vitamin K oral anticoagulants (NOACs). We aimed to identify risk factors in a large...

TRIPLE THERAPY - WALKING ON A TIGHT ROPE!

Managing patients with atrial fibrillation (AF) requiring percutaneous interventionor those on anticoagulant therapy needing an intervention is an act of greatbalancing like walking on a tight rope. The premise revolves around three basicconsiderations - the risk of embolism and stroke due to AF, the possibility ofthrombosis due to underlying coronary obstructive disease and interventionsand more importantly the hazard of bleeding in combining different therapeuticagents. Risk of thromboembolic stroke is determined by a host of factors. CHA DS VASC score is well-validated risk score based onage, gender and comorbidities. It identifies patients at higher risk of thromboembolism who require anticoagulants to preventstroke. HASBLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile internationalnormalized ratio [INR], elderly [>65 years], drugs/alcohol concomitantly) has been recommended as a bleeding risk score forpatients with AF, with scores Ý3 considered high risk. Both scores have to be used with a grain of common sense andconsidering patient as a whole, though the HAS-BLED score has been credited to predict bleeding significantly; thediscriminating value is overall limited and similar to CHA DS VASC score. A brief period of washout from the anticoagulant effect of OAC is preferable whenever possible in elective and non-emergentprocedures. In patients on Vit K antagonists, those being subjected to radial approach, INR should be preferably U2.0 and iffemoral approach is used INR has to be U 1.5. In patients on NOAC, irrespective of vascular access site, treatment may bewithheld for 24 hours (or 48 hours for patients with impaired renal function with dabigatran). Although in stable CAD patientsbridging with parenteral anticoagulation can be omitted yet this should be considered for patients presenting with an ACS. To conclude, treating patients with triple therapy in the setting of AF and PCI is like walking on a tight rope. Three importantconsiderations for all decisions making are risk of thrombo-embolism and stroke, risk for thrombotic complications and risk ofbleeding. Meticulous management is recommended pre, intra and post procedure. This entails selecting patients usingappropriate criteria, employing radial approach, using latest generation DES, starting triple therapy and then changing over toSAPT earlier or later balancing thrombotic versus bleeding risks.

P1580Performance of atrial fibrillation ischemic and bleeding risk scores in patients with cancer

P1580Performance of atrial fibrillation ischemic and bleeding risk scores in patients with cancer

235Stroke and bleeding risk scores in patients with atrial fibrillation and valvular heart disease: prospective validation of the EHRA classification in a nationwide cohort study

235Stroke and bleeding risk scores in patients with atrial fibrillation and valvular heart disease: prospective validation of the EHRA classification in a nationwide cohort study

P6356The ARDVAARC study: real-world outcomes and the utility of bleeding risk scores in patients who require anticoagulation following percutaneous coronary intervention (PCI)

P6356The ARDVAARC study: real-world outcomes and the utility of bleeding risk scores in patients who require anticoagulation following percutaneous coronary intervention (PCI)

P2296Association of left atrial size with ischemic and bleeding risk scores in patients with non-valvular atrial fibrillation

P2296Association of left atrial size with ischemic and bleeding risk scores in patients with non-valvular atrial fibrillation

Comparison of CRUSADE and ACUITY-HORIZONS Bleeding Risk Scores in Patients With Acute Coronary Syndromes

Compare the discriminative performance of two validated bleeding risk models for in-hospital bleeding events in a non-selected cohort of acute coronary syndrome (ACS) patients. CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines) and ACUITY-HORIZONS (Acute Catheterization and Urgent Intervention Triage strategY-Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) scores were calculated in 501 consecutive patients (median age 68 years (IQR 57-77), 31% female) admitted for ACS to the coronary care unit (CCU) of San Paolo Hospital in Milan (Italy). In-hospital haemorrhagic events and mortality were recorded and calibration and discrimination of the two risk models were evaluated using the Hosmer-Lemeshow test and the C-statistic, respectively. Overall bleeding events were observed in 32 patients and major bleedings in 11 (with an incidence of 6.4% and 2.2%, respectively). In-hospital mortality was 2.6%. Regarding major bleedings both risk scores demonstrated an adequate calibration (H-L test p>0.20) and a moderate discrimination with no significant difference in predictive accuracy between the two models (C-statistic 0.69 for CRUSADE and 0.73 for ACUITY-HORIZONS). We also tested the performance of the two risk models in predicting in-hospital mortality, showing an adequate calibration and a very good discrimination (C-statistic 0.88 and 0.89 for the CRUSADE and ACUITY-HORIZONS scores, respectively), with no significant difference in predictive accuracy. In our ACS population the CRUSADE and the ACUITY-HORIZONS risk scores showed a fairly good and comparable predictive accuracy regarding in-hospital bleeding events and they appeared to be very good predictors of in-hospital mortality.