CRUSADE Risk Score Research Articles

Using the ORACLE Risk Score to Assess Hemorrhagic Risk in Patients with Acute Coronary Syndrome and Atrial Fibrillation

Aim. To study the prognostic value of the ORACLE risk score for assessing the risk of bleeding in patients with acute coronary syndrome (ACS) undergoing anticoagulants for atrial fibrillation using the combined database of the ORACLE II and RECORD 3 registers.Material and methods. This analysis included patients with ACS from 2 observational studies: ORACLE II (ObseRvation after Acute Coronary syndrome for deveLopment of trEatment options; n=1803) and the RECORD-3 register (n=2370). In total, the database included 4173 patients, of which 246 (6.08%) received oral anticoagulants for atrial fibrillation. The mean age of patients was 64.7±11.9 years, 2493 (59.7%) were men. Hemorrhagic risk was assessed using the ORACLE, CRUSADE, ORBIT, and HAS-BLED risk score.Results. Patients receiving anticoagulant therapy were older (69.9±11.3 years and 64.0±12.2 years, p<0.001). Among these patients there was a larger proportion of women, and a smaller proportion of patients with ACS with ST elevation, they were more likely to have chronic heart failure, chronic kidney disease, history of stroke. Among patients receiving anticoagulants and included in the ORACLE study, the frequency of percutaneous coronary intervention was higher than in patients included in the RECORD study. In the joint database, 71 significant bleeding was recorded during the hospitalization period – 64 (1.7%) in patients without anticoagulants and 7 (2.8%) among patients taking anticoagulants (p=0.06). Over 6 months, among patients who did not receive anticoagulants, there were 97 cases of bleeding (in 2.6% of patients), in the group of patients receiving anticoagulants – 12 cases of bleeding (4.9%) – the differences in frequency were significant (p=0.029). The ORACLE risk score had the greatest prognostic value (area under the ROC curve 0.874±0.0416, sensitivity 82.7%, specificity 79.1%). The predictive value of the HAS-BLED risk score was slightly lower (area under the ROC curve 0.710±0.0360, sensitivity 63.2%, specificity 56.8%). The value of the CRUSADE risk score (area under the ROC curve 0.612±0.0269, sensitivity 53.7%, specificity 59.5%) and ORBIT risk score (area under the ROC curve 0.606±0.0457, sensitivity 62.5%, specificity 58.3%) were lower (p<0.001 for all scales).Conclusion. The use of the ORACLE bleeding risk score can be recommended for patients with ACS requiring anticoagulant therapy.

P4622Prediction of in-hospital bleeding for AMI patients undergoing PCI using machine learning method

Abstract Background Prediction of in-hospital bleeding is critical for clinical decision making for acute myocardial infarction (AMI) patients undergoing percutaneous coronary intervention (PCI). Machine learning methods can automatically select the combination of the important features and learn their underlying relationship with the outcome. Objective We aim to evaluate the predictive value of machine learning methods to predict in-hospital bleeding for AMI patients. Methods We used data from the multicenter China Acute Myocardial Infarction (CAMI) registry. We randomly partitioned the cohort into derivation set (75%) and validation set (25%). Using data from the derivation set, we applied a state-of-art machine learning algorithm, XGBoost, to automatically select features from 106 candidate variables and train a risk prediction model to predict in-hospital bleeding (BARC 3, 5 definition). Results 16736 AMI patients who underwent PCI were consecutively included in the analysis, while 70 (0.42%) patients had in-hospital bleeding followed the BARC 3,5 definition of bleeding. Fifty-nine features were automatically selected from the candidate features and were used to construct the prediction model. The area under the curve (AUC) of the XGBoost model was 0.816 (95% CI: 0.745–0.887) on the validation set, while AUC of the CRUSADE risk score was 0.723 (95% CI: 0.619–0.828). Relative contribution of the 12 most important features Feature Relative Importance Direct bilirubin 0.078 Heart rate 0.077 CKMB 0.076 Creatinine 0.064 GPT 0.052 Age 0.048 SBP 0.036 TG 0.035 Glucose 0.035 HCT 0.031 Total bilirubin 0.030 Neutrophil 0.030 ROC of the XGBoost model and CRUSADE Conclusion The XGBoost model derived from the CAMI cohort accurately predicts in-hospital bleeding among Chinese AMI patients undergoing PCI. Acknowledgement/Funding the CAMS innovation Fund for Medical Sciences (CIFMS) (2016-12M-1-009); the Twelfth Five-year Planning Project of China (2011BAI11B02)

Assessment of the prognostic value of the CRUSADE score in Algerian patients with NSTE-ACS treated with an invasive approach

The CRUSADE score was created for assessment of bleeding risk in patients with acute coronary syndrome (ACS). However, its accuracy was not confirmed in populations of patients treated in Algerian hospitals. To examine the value of CRUSADE bleeding score in predicting bleeding events in patients with NSTE-ACS managed invasively. Our study included 296 patients with NSTE-ACS. They underwent history and clinical examination; 12-lead electrocardiography; echocardiography; coronarography, troponin T us; hematocrit value; estimated glomerular filtration rate (eGFR); application of CRUSADE score; and a one year follow-up with documentations of events. Patients were classified into two groups: Group I: patients with major bleeding (BARC ≥ 3), and Group II: patients without major bleeding. Sixteen (5.4%) patients had a major bleeding events, seven (2.4%) during the initial in-hospital period and nine (3%) during the follow-up after discharge. Patients with major bleeding events were significantly older (69 ± 12 vs.61 ± 12 years, P = 0.024), with more diabetic (9.3% vs. 1.9%, P = 0.008), lower hematocrit (34.1 ± 5.3% vs.40.2 ± 5.2%, P < 0.0001), lower eGFR (65.6 ± 32.4 mL/min vs.85.2 ± 36.4 mL/min, P = 0.036), and higher CRUSADE risk score. Crusade score measurement in patients with major bleeding was significantly higher than in those without coronary artery disease (36.9 ± 14.1 vs. 27.1 ± 13.1; P = 0.004). CRUSADE bleeding score was the strongest predictor of major bleeding. Sensitivity of CRUSADE score ≥ 38 in prediction of major bleeding in the whole study group was 62.5%, specificity was 79.6%, and overall accuracy was 70.0%. CRUSADE score is a good predictor for one-year major bleeding events in Algerian patients with NSTE-ACS treated with an invasive approach.

Incidence and predictors of bleeding among Egyptian patients presenting with acute coronary syndrome: Using CRUSADE risk score.

BackgroundEarly invasive strategies; in management of acute coronary syndrome; has led to improvement of patient outcomes. However, these invasive therapies have their own risks, namely bleeding and blood transfusion.The aim of this study was to determine the incidence of bleeding, its location and severity among the study population, to correlate between the patients' characteristics and the risk profile of the patients based upon the CRUSADE risk score and increased bleeding events, and lastly; to identify the predictors of increased bleeding risk among Egyptian patients who presented with acute coronary syndrome.MethodsThe study had included eight hundred and twenty-three patients referred to coronary care unit (CCU), to (Ain Shams University hospital, Specialized Ain Shams hospital, and 6th October insurance hospital) with diagnosis of Acute Coronary Syndrome “ACS” within a period from 1/2014 till 7/2014, and they were followed up for additional three months following discharge with assessment of their bleeding risk and risk scores.ResultsMore bleeding events had been witnessed among the study population who were older, diabetics, had renal impairment, had peripheral vascular disease, had congestive heart failure picture at presentation; more among female sex category and more among patients receiving GPIIbIIIa antagonists. Those bleeding events had been experienced during hospital stay.ConclusionRisk of bleeding can be evaluated using a simple risk score in both STEMI & NSTEMI patients, and across anti-coagulant strategies, providing important prognostic information. Variability in the rates of bleeding is likely based on differences in baseline characteristics, comorbidities, and invasive treatment strategies rather than specific anti-coagulation regimens. Patients at highest risk of bleeding are also at highest risk of ischaemia and thrombotic complications. Thus higher risk patients need a more careful treatment approach to maximize the efficacy of therapy and to reduce thrombotic risk while reducing the bleeding risk.

Evaluation of the CRUSADE Risk Score for Predicting Major Bleeding in Patients with Concomitant Kidney Dysfunction and Acute Coronary Syndromes

Background: Kidney dysfunction (KD) has been associated with increased risk for major bleeding (MB) in patients with acute coronary syndromes (ACS) and may be in part related to an underuse of evidence-based therapies. Our aim was to assess the predictive ability of the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE) risk score in patients with concomitant ACS and chronic kidney disease. Methods: We conducted a retrospective analysis of a prospective registry including 1,587 ACS patients. In-hospital MB was prospectively recorded according to the CRUSADE and Bleeding Academic Research Consortium (BARC) criteria. KD was defined as an estimated glomerular filtration rate <60 mL/min/1.73 m². Results: The predictive ability of the CRUSADE risk score was assessed by discrimination and calibration analyses. A total of 465 (29%) subjects had KD. In multivariate logistic regression analyses, we found high CRUSADE risk score values to be associated with a higher rate of in-hospital MB; however, among patients with KD, it was not associated with BARC MB. Regardless of the MB definition, the predictive ability of the CRUSADE score in patients with KD was lower: area under the curve (AUC) 0.71 versus 0.79, p = 0.03 for CRUSADE MB and AUC 0.65 versus 0.75, p = 0.02 for BARC MB. Hosmer-Lemeshow analyses showed a good calibration in all renal function subgroups for both MB definitions (all p values >0.3). Conclusions: The CRUSADE risk score shows a lower accuracy for predicting in-hospital MB in KD patients compared to those without KD.

Predictive performance of adding platelet reactivity on top of CRUSADE score for 1-year bleeding risk in patients with acute coronary syndrome.

CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress Adverse outcomes with Early implementation of the ACC/AHA guidelines) risk score can independently predict major bleeding events in patients with non-ST elevation myocardial infarction whereas the discriminative capacity is moderate. Whether adding platelet reactivity on top of CRUSADE score improves the prognostic performance for bleeding remains unclear. 512 patients with acute coronary syndrome (ACS) underwent successful percutaneous coronary intervention were enrolled and 1-year data were available. CRUSADE risk score was calculated at hospital admission and P2Y12 reaction unit (PRU) value was measured by VerifyNow P2Y12 assay. Thirty-five (6.8%) patients experienced major bleeding events within 1-year follow-up. Patients who developed bleeding complications had higher CRUSADE score (37.5±9.4 vs. 29.0±10.2, p<0.001) and lower PRU value (149.7±57.1 vs. 196.4±51.4, p<0.001) than those did not. Both CRUSADE score and platelet reactivity were independently associated with bleeding. Kaplan-Meier analysis showed that patients with high CRUSADE score plus low platelet reactivity had significantly elevated risk for bleeding (HR 7.905, 95% CI 2.623-23.822, p<0.001). Compared to CRUSADE score alone, adding platelet reactivity on top of CRUSADE score offered a discriminative increment which was demonstrated by c-statistic (0.827 vs. 0.732, p=0.011), as well as net reclassification improvement (NRI=0.258, p<0.001) and integrated discrimination improvement (IDI=0.022, p=0.002). After successful coronary stent implantation in patients with ACS, combining CRUSADE score with platelet reactivity yielded more accurate predictive value for 1-year bleeding risk.

Comparison of the Global Registry of Acute Coronary Events Risk Score Versus the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse outcomes With Early Implementation of the ACC/AHA Guidelines Risk Score to Predict In-Hospital Mortality and Major Bleeding in Acute Coronary Syndromes

Risk assessment plays a major role in the management of acute coronary syndrome. The aim was to compare the performance of the Global Registry of Acute Coronary Events (GRACE) and the Can Rapid risk stratification of Unstable angina patients Suppress Adverse outcomes with Early implementation of the American College of Cardiology/American Heart Asociation guidelines (CRUSADE) risk scores to predict in-hospital mortality and major bleeding (MB) in 1,587 consecutive patients with acute coronary syndrome. In-hospital deaths and bleeding complications were prospectively collected. Bleeding complications were defined according to CRUSADE and Bleeding Academic Research Consortium (BARC) criteria. During the hospitalization, 71 patients (4.5%) died, 37 patients (2.3%) had BARC MB and 34 patients (2.1%) had CRUSADE MB. Receiver operating characteristic curves analyses showed GRACE risk score has better discrimination capacity than CRUSADE risk score for both, mortality (0.86 vs 0.79; p = 0.018) and BARC MB (0.80 vs 0.73; p = 0.028), but similar for CRUSADE MB (0.79 vs 0.79; p = 0.921). Both scores had low discrimination for predicting MB in the elderly (>75 years) and patients with atrial fibrillation, whereas CRUSADE risk score was especially poor for predicting MB in patients with <60 ml/min/1.73 m(2) or those treated with new antiplatelets. Reclassification analyses showed GRACE risk score was associated with a significant improvement in the predictive accuracy of CRUSADE risk score for predicting mortality (net reclassification improvement: 22.5%; p <0.001) and MB (net reclassification improvement: 17.6%; p = 0.033) but not for CRUSADE MB. In conclusion, GRACE risk score has a better predictive performance for predicting both in-hospital mortality and BARC MB. In light of these findings, we propose the GRACE score as a single score to predict these in-hospital complications.

History of previous bleeding and C-reactive protein improve assessment of bleeding risk in elderly patients (≥ 80 years) with myocardial infarction.

We aimed to assess whether the CRUSADE risk score represents a robust instrument for stratification of bleeding risk in elderly myocardial infarction (MI) patients (≥ 80 years) and further aimed to identify age-specific predictors of major bleeding events. Binary logistic regression models were applied to assess the effect of variables on the occurrence of bleeding events during hospital stay. Receiver operating characteristic (ROC) analysis was used to evaluate the discriminatory power. Out of 387 patients in the final study cohort, 74 patients (19.1 %) experienced a major bleeding event according to the definition of the International Society on Thrombosis and Haemostasis. The CRUSADE risk score demonstrated only a weak discriminatory power to predict bleeding in this group of patients (area under the ROC curve: 0.57 [0.51-0.65]; p=0.05). In the multivariate regression analysis, history of bleeding with an adjusted hazard ratio (HR) of 3.21 (95 % confidence interval: 1.29-8.03, p=0.01) and C-reactive protein with an adjusted HR per increase of 10 mg/l of 1.05 (1.01-1.10) were independent predictors of major bleeding. Integration of both variables into the CRUSADE score demonstrated a significantly improved performance for bleeding as indicated by a significant increase in the ROC analysis (area under the curve: 0.64 vs 0.57; for comparison p< 0.045), net reclassification index (35.6 %; p=0.006) and integrated discrimination increment (0.0242; p=0.02). In conclusion, bleeding history and C-reactive protein significantly improve the modest predictive power of the CRUSADE risk score in elderly patients with MI. These results point towards a specific risk profile for bleeding events in this high-risk group of patients.

Use of the CRUSADE Bleeding Risk Score in the Prediction of Major Bleeding for Patients with Acute Coronary Syndrome Receiving Enoxaparin in Thailand

CRUSADE risk score stands out as a simple-to-use bleeding risk model. However, its use is still doubtful for Thai population. The aim of this study was to assess the prognostic value of CRUSADE in predicting risk of major bleeding among Thai patients with acute coronary syndrome (ACS) receiving enoxaparin. A retrospective cohort study was performed using patients with ACS who were hospitalised at a university hospital in Bangkok between 2006 and 2009 and had received enoxaparin. The CRUSADE risk score was calculated. The model validation was tested by using C statistic and Hosmer-Lemeshow goodness-of-fit. The overall incidence of major bleeding was 18.3%. Median CRUSADE score for entire study population, unstable angina (UA), non-ST elevation myocardial infarction (NSTEMI), and ST elevation myocardial infarction (STEMI) were 49, 47, 53, and 39, respectively. Hosmer-Lemeshow goodness of fit revealed no statistical significance in all groups. The CRUSADE model demonstrated a satisfactory discriminatory capacity for the entire study population (C = 0.688), UA (C = 0.591), NSTEMI (C = 0.693), and STEMI groups (C = 0.736). Across the ACS spectrum, CRUSADE risk score was able to estimate in-hospital major bleeding of Thai patients with ACS who received treatment with enoxaparin. The application of these results in Thailand may be helpful in the identification of patients at high bleeding risk and also may lead to implementation of appropriate prevention.

Beta-Trace Protein and Cystatin C as Predictors of Major Bleeding in Non-ST-Segment Elevation Acute Coronary Syndrome

Beta-trace protein (BTP) and cystatin C (CysC) are novel biomarkers of renal function. We assessed the ability of both to predict major bleeding (MB) in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS), compared to other renal function parameters and clinical risk scores. We included 273 patients. Blood samples were obtained within 24h of admission. The endpoint was MB. During a follow-up of 760 days (411-1,098 days), 25 patients (9.2%) had MB. Patients with MB had higher concentrations of BTP (0.98 mg/L; 0.71-1.16 mg/L vs. 0.72 mg/L, 0.60-0.91 mg/L, P=0.002), CysC (1.05 mg/L; 0.91-1.30 mg/L vs. 0.90 mg/L, 0.75-1.08 mg/L, P=0.003), higher CRUSADE score (39 ± 16 points vs. 29 ± 15 points, P=0.002) and lower estimated glomerular filtration rate (eGFR; 66 ± 27 vs. 80 ± 30 ml·min(-1)·1.73 m(-2), P=0.02) than patients without MB; there was no difference in creatinine level between the groups (P=0.14). After multivariable adjustment, both were predictors of MB, while eGFR and creatinine did not achieve statistical significance. Among subjects with eGFR >60 ml·min(-1)·1.73 m(-2), those with elevated concentrations of both biomarkers had a significantly higher risk for MB. Net reclassification indexes from the addition of BTP and CysC to CRUSADE risk score were 38% and 21% respectively, while the relative integrated discrimination indexes were 12.5% and 3.8%. Among NSTE-ACS patients, BTP and CysC were superior to conventional renal parameters for predicting MB, and improved clinical stratification for hemorrhagic risk.

Predicting long-term mortality in older patients after non–ST-segment elevation myocardial infarction: The CRUSADE long-term mortality model and risk score

We sought to develop a long-term mortality risk prediction model and a simplified risk score for use in older patients with non-ST-segment elevation myocardial infarction (NSTEMI). Limited data are available regarding long-term mortality rates and concomitant risk predictors after acute myocardial infarction in contemporary community practice. From the CRUSADE registry, a total of 43,239 (NSTEMI) patients aged ≥65 years treated at 448 hospitals in the United States from 2003 to 2006 were linked to Centers for Medicare and Medicaid Services data to track longitudinal all-cause mortality (median follow-up 453 days). Cox proportional hazard modeling was used to determine baseline independent demographic, clinical, and laboratory variables associated with long-term mortality. A simplified long-term mortality risk score was subsequently developed from these results. The median age of this population was 77 years, and mortality rates at 1, 2, and 3 years were 24.4%, 33.2%, and 40.3%, respectively. We identified 22 variables independently associated with long-term mortality in a full model (c-statistic 0.754 in the derivation sample and 0.744 in the validation sample). The CRUSADE long-term mortality risk score was limited to the 13 most clinically and statistically significant variables from the full model yet retained comparable discrimination in the derivation and validation samples (c-statistics 0.734 and 0.727, respectively) and had good calibration across the risk spectra. Older patients face substantial long-term mortality risks after NSTEMI that can be accurately predicted from baseline characteristics. These prognostic estimates may support informed treatment decision-making and comparison of long-term provider outcomes.

Evaluating the Performance of the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines (CRUSADE) Bleeding Score in a Contemporary Spanish Cohort of Patients With Non–ST-Segment Elevation Acute Myocardial Infarction

The Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines (CRUSADE) model provides a risk score that predicts the likelihood of major bleeding in patients hospitalized for non-ST-elevation acute myocardial infarction. The aim of the present work was to evaluate the performance of this model in a contemporary cohort of patients hospitalized for non-ST-elevation acute myocardial infarction in Spain. The study subjects were 782 consecutive patients admitted to our center between February 2004 and June 2009 with non-ST-elevation acute myocardial infarction. For each patient, we calculated the CRUSADE risk score and evaluated its discrimination and calibration by the C statistic and the Hosmer-Lemeshow goodness-of-fit test, respectively. The performance of the CRUSADE risk score was evaluated for the patient population as a whole and for groups of patients treated with or without >or=2 antithrombotic medications and who underwent cardiac catheterization or not. The median CRUSADE score was 30 points (range, 18 to 45). A total of 657 patients (84%) were treated with >or=2 antithrombotic, of whom 609 (92.7%) underwent cardiac catheterization. The overall incidence of major bleeding was 9.5%. This incidence increased with the risk category: very low, 1.5%; low, 4.3%; moderate, 7.8%; high, 11.8%; and very high, 28.9% (P<0.001). For the patients as a whole, for the groups treated with or without >or=2 antithrombotics, and for the subgroup treated with >or=2 antithrombotics who did or did not undergo cardiac catheterization, the CRUSADE score showed adequate calibration and excellent discriminatory capacity (Hosmer-Lemeshow P>0.3 and C values of 0.82, 0.80, 0.70, and 0.80, respectively). However, it showed little capacity to discriminate bleeding risk in patients treated with >or=2 antithrombotics who did not undergo cardiac catheterization (C=0.56). The CRUSADE risk score was generally validated and found to be useful in a Spanish cohort of patients treated with or without >or=2 antithrombotics and in those treated with or without >or=2 antithrombotics who underwent cardiac catheterization. More studies are needed to clarify the validity of the CRUSADE score in the subgroup treated with >or=2 antithrombotics who do not undergo cardiac catheterization.