CRUSADE Score Research Articles

Prognostic Impact of in-Hospital-Bleeding in Patients With ST-Elevation Myocardial Infarction Treated by Primary Percutaneous Coronary Intervention

Several studies established a link between bleeding and mortality in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI); however, it is unclear whether bleeding has a direct role in worsening the prognosis or if it is simply a marker of patient frailty. We investigated whether bleeding is an independent predictor of mortality in patients with STEMI treated with pPCI. The relationship between the presence of heart failure on presentation (Killip classification), bleeding occurrence, and outcome was also assessed. Bleeding was defined as the combination of Thrombolysis in Myocardial Infarction major and minor bleeding. Short- and long-term mortalities were estimated using the Kaplan-Meyer analysis. Multivariable analysis was performed by the Cox regression model. As an alternative method to address the potential confounding factors, we performed a propensity-matched analysis adjusted for all variables included in the CRUSADE score. In the 1,911 consecutive patients with STEMI considered, bleeding (observed in 11.4% of patients) was an independent predictor of 30-day (hazard ratio 2.61, 95% confidence interval 1.30 to 5.25, p = 0.007) and 1-year mortality (hazard ratio 1.98, 95% confidence interval 1.13 to 3.47, p = 0.017) but not in a landmark analysis starting from 30 days to 1 year. Bleeding was significantly associated with higher 30-day and 1-year mortality in patients with Killip class ≥II, but not in patients with Killip class I. In conclusion, in-hospital bleeding is independently associated with increased mortality in the early period after STEMI, also after adjusting for variables associated with the risk of bleeding. Bleeding was associated with increased mortality in patients with signs of heart failure at admission, whereas it had no effects in patients with Killip class I.

Additive value of the CRUSADE score to the GRACE score for mortality risk prediction in patients with acute coronary syndromes

IntroductionAcute coronary syndrome (ACS) treatments increase bleeding complications that also impair prognosis. Bleeding risk scores reclassification of actual mortality risk estimated by the GRACE score might improve overall estimation. MethodsObservational and prospective study of all ACS patients admitted in two hospitals. Mortality risk was assessed by the GRACE score and bleeding risk by the CRUSADE score. We analyzed the net reclassification improvement (NRI) of adding the CRUSADE score to the GRACE score. ResultsWe included 6997 patients, mean age 67.4 (12.9), 38.0% ST-elevation ACS, mean GRACE score 145.2 (39.9). The percentage of patients with CRUSADE score >20 or >50 increased as the GRACE score was higher. Hospital mortality was 5.3% and the addition of the CRUSADE score reclassified a relevant percentage of patients with GRACE score >109; NRI was 3.80% (1.10–6.10). During follow-up, (median 53.0months) mortality rate was 22.6% and patients with CRUSADE score >50 had significantly higher mortality rates in all GRACE score categories; NRI was high (46.6%, 95% CI 41.0–53.1). The multivariate analysis outlined the independent predictive value of CRUSADE score >20 or >50 as well as GRACE scores 109–139 and >140. ConclusionsThe addition of the CRUSADE score to the GRACE score improved mortality risk estimation. A CRUSADE score >50 identified patients with higher post-discharge mortality and higher hospital mortality if GRACE score was >109. The CRUSADE score improved hospital and long-term mortality prediction in patients with GRACE score >140. Individual mortality risk estimation should integrate the CRUSADE and GRACE scores.

P6462Comparison of the performance of the CRUSADE, ACUITY-HORIZONS, and ACTION bleeding scores in ACS patients undergoing PCI: insights from a cohort of 4939 patients in China

P6462Comparison of the performance of the CRUSADE, ACUITY-HORIZONS, and ACTION bleeding scores in ACS patients undergoing PCI: insights from a cohort of 4939 patients in China

P6108ACUITY risk score better predicts 30-days major cardiovascular events than CRUSADE and GRACE risk scores in acute coronary syndrome

P6108ACUITY risk score better predicts 30-days major cardiovascular events than CRUSADE and GRACE risk scores in acute coronary syndrome

Baseline anemia in patients undergoing percutaneous coronary intervention after an acute coronary syndrome-A paradox of high bleeding risk, high ischemic risk, and complex coronary disease.

To define more clearly the associations between baseline anemia, bleeding/ischemia risk, coronary disease severity, and outcomes by revascularization completeness. Anemia is associated with adverse outcomes in patients presenting with an acute coronary syndrome (ACS). Data was sourced from hospital databases for patients admitted with an ACS to a single center between 2011 and 2014. Using WHO anemia criteria, 468 (26.9%) of 1731 patients were anemic. In anemic patients, the mean CRUSADE score (34.6 ± 16.9 vs 24.6 ± 13.4, P < 0.0001), mean GRACE scores (165.8 ± 44.9 vs 141.6 ± 40.1, P < 0.0001), and percentage of patients with a high/very high CRUSADE score combined with a high GRACE score (69.3 vs 48.3%, P < 0.0001) was much greater than non-anemic patients. Patients with baseline anemia were more likely to have left main or chronic occlusive disease, and more diseased vessels. The percentage of patients with residual disease (41.2 vs 30.7%, P < 0.0001), the number of residual diseased vessels (0.59 ± 0.83 vs 0.42 ± 0.72, P < 0.0001), and the percentage with a residual CTO (62.4 vs 56.4%, P = 0.036) were all higher than in non-anemic patients. The duration of anti-platelet therapy was significantly shorter in anemic patients (7.8 ± 4.3 vs 11.2 ± 2.4 months, P < 0.001). At 12-months, mortality and stent thrombosis were more likely to occur in anemic patients, with the number of residual vessels associated with adverse survival regardless of anemia status. Patients with anemia present with high ischemia and bleed risk scores, complex coronary disease, and have adverse outcomes. Incomplete revascularization was associated with worse survival regardless of anemia status.

CRUSADE Score is Superior to Platelet Function Testing for Prediction of Bleeding in Patients Following Coronary Interventions

Hypothetically, diminished platelet reactivity (PR) during dual antiplatelet therapy (DAPT) should cause extra major bleeding events (MBE), although definite evidence is lacking. Multiple scores have been proposed to stratify bleeding risk, but their predictive value during DAPT is unclear. We compared the performance of the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) with PR testing to predict MBE in Korean patients with acute coronary syndrome. We screened 1105, and included 903 consecutive patients who underwent coronary interventions. All patients received DAPT, while MBE were assessed by BARC scale. Admission platelet reactivity was assessed with VerifyNow Analyzer simultaneously with CRUSADE score, and MBE were collected at 1month and at 1year post stenting. There were a total of 113 (11%) MBE at 1month, and extra 41(5%) MBE at 1year. At 1month MBE prediction was superior by CRUSADE score (AUC: 0.816, 95% CI: 0.79 0.84, p<0.0001), compared to PR (AUC: 0.605, 95% CI: 0.572–0.637, p=0.0007). Moreover, CRUSADE score remains the independent predictor of MBE by multivariate analyses (OR=2.94, 95% CI: 2.18–3.96, p<0.0001). At 1year MBE also correlated, but were not significantly different between admission CRUSADE score (AUC: 0.62, 95% CI: 0.58 0.66, p=0.0183) and PR (AUC: 0.674, 95% CI: 0.63–0.71, p=0.002). We conclude that MBE are more common in real life than reported in clinical trials. CRUSADE score was superior to PR testing for predicting short-term, but not 1year MBE in Korean patients undergoing percutaneous coronary intervention and treated with DAPT.

70 Clinical outcomes of clopidogrel versus ticagrelor in the elderly patients with acute coronary syndrome

BackgroundAcute coronary syndrome (ACS) remains one of the leading causes of death in the UK. One of the recent advances in treatment in the treatment of ACS is ticagrelor, a...

Validación y comparación de los puntajes CRUSADE y ACTION para predecir el riesgo de sangrado en pacientes con síndrome coronario agudo sin elevación del segmento ST

Objetivo: validar y comparar las escalas de riesgo de sangrado CRUSADE y ACTION en pacientes con síndrome coronario agudo sin elevación del segmento ST (SCASEST) llevados a estratificación coronaria invasiva temprana en un centro de alta complejidad. &#x0D; &#x0D; Métodos: estudio de tipo observacional, analítico y prospectivo, de validación de escalas en una cohorte de pacientes con SCASEST llevados a estratificación coronaria invasiva temprana en un centro cardiovascular. Las escalas de riesgo CRUSADE y ACTION fueron calculadas con las características basales. La ocurrencia de sangrado mayor fue definido por hemorragia intracerebral, retroperitoneal, caída del hematocrito ≥ 12% o necesidad de transfusión cuando el hematocrito fuera &gt; 3 g/dL o ≥ 28% o &lt; 28% con documentación de sangrado clínico o sangrado no relacionado con cirugía de revascularización.&#x0D; &#x0D; Resultados: en este análisis la tasa de sangrado mayor observada fue de 4.8%. La presencia de sangrado mayor se asoció con una probabilidad mayor de mortalidad durante el seguimiento a seis meses (OR 5.316; IC 95% 1.77 -15.92; p= 0.002). La calibración de las escalas de riesgo fue adecuada de acuerdo al estadístico Hosmer-Lemeshow (p&gt;0.05). Ambas escalas demostraron buena discriminación sin diferencias estadísticamente significativas en el escenario intrahospitalario (AUC ROC CRUSADE ACTION 0.77 vs 0.80 p=0.19), al mes (AUC ROC CRUSADE ACTION 0.70 vs 0.75 p=0.08) y 6 meses (AUC ROC CRUSADE ACTION 0.71 vs 0.76 p=0.09), respectivamente. &#x0D; &#x0D; Conclusiones: las escalas de riesgo CRUSADE y ACTION son herramientas útiles para la predicción del riesgo de sangrado en pacientes con SCASEST llevados a estratificación coronaria invasiva temprana. Estos hallazgos sugieren el uso de la escala ACTION sobre la escala de riesgo CRUSADE.

Ticagrelor versus clopidogrel in real-world patients with ST elevation myocardial infarction: 1-year results by propensity score analysis

BackgroundEuropean guidelines recommend the use of ticagrelor versus clopidogrel in patients with ST elevation myocardial infarction (STEMI). This recommendation is based on inconclusive results and subanalyses from clinical trials. Few data are available on the effects of ticagrelor in a real-world population.MethodsTo compare the effects of ticagrelor and clopidogrel in a real-world STEMI population, we conducted a pre-post case-control study examining all patients with STEMI included in the Cardio-STEMI Sanremo registry between February 2011 and June 2013. Cases and controls were defined according to P2Y12 inhibitors, correcting the bias due to lack of randomization by propensity score analysis. Ticagrelor was introduced in 2012 in both in-hospital and pre-hospital settings independently of this study.ResultsOf the 416 patients enrolled in the Cardio-STEMI registry, 401 with a definite diagnosis of STEMI were included in this study. One hundred forty-two patients received ticagrelor and 259 received clopidogrel. Regarding clinical presentation and procedural data, those in the ticagrelor group had lower CRUSADE scores (23 [14–36] vs 27 [18–38]; p = 0.015] but a higher proportion of radial access (33% vs 14%; p < 0.001), percutaneous coronary intervention (PCI; 92% vs 81 %; p = 0.002) and primary PCI ≤ 12 h (82% vs 66%; p = 0.001). The patients in the ticagrelor group had a higher procedural success rate (100% vs. 96%; p = 0.044). There was no difference in Bleeding Academic Research Consortium bleeding and in unadjusted incidence of hospital major adverse cardiovascular events (MACE; cardiac death, myocardial infarction, or stroke) but there was a significant reduction in unadjusted cardiac hospital death in the ticagrelor group (0.7% vs 5.4%; p = 0.024). After correcting for propensity score, hospital death (p = 0.22) and hospital MACE (p = 0.96) did not differ in both groups. The unadjusted survival at 1 year after STEMI was higher in the ticagrelor group (97.8% vs 87.8%; p = 0.024), and this result was confirmed by propensity score analysis (hazard ratio = 0.29 [0.08–0.99]; p = 0.048).ConclusionsIn this real-word propensity score analysis, ticagrelor did not affect the risk of MACE during the hospital phase, or the incidence of hospital bleeding in patients with STEMI. However, in this mono-centric experience, ticagrelor resulted in improved 1-year survival, even after correction by propensity score.

Comparison of the performance of the CRUSADE, ACUITY-HORIZONS, and ACTION bleeding scores in ACS patients undergoing PCI: insights from a cohort of 4939 patients in China.

BackgroundThe CRUSADE, ACTION and ACUITY-HORIZONS scores are commonly used for predicting in-hospital major bleeding events in patients with acute coronary syndrome (ACS), but the homogeneous nature of these models' population limits simple extrapolation to other local population. We aimed to compare the performance of the three risk models in Chinese patients.MethodsWe evaluated the performance of the three predicting scores for predicting in-hospital major bleeding events defined by thrombolysis in myocardial infarction (TIMI) serious (major and minor) episodes, in a cohort of Chinese ACS patients with either non-ST-elevation ACS (NSTE-ACS) or ST-elevation myocardial infarction (STEMI). Calibration and discrimination of the three risk models were evaluated by the Hosmer-Lemeshow test and C-statistic, respectively. We compared the predictive accuracy of the risk scores by the Delong non-parametric test.ResultsTIMI serious bleeding rate was 1.1% overall (1.9% and 0.86% for STEMI and NSTE-ACS, respectively). The CRUSADE, ACTION and ACUTIY-HORIZONS scores showed an adequate discriminatory capacity for major bleeding: in overall patients, the C-statistic was 0.80, 0.77, and 0.70, respectively; in NSTE-ACS patients, the C-statistic was 0.73, 0.72, and 0.64, respectively; in STEMI patients, the C-statistic was 0.91, 0.92, and 0.75, respectively. The C-statistic for the ACUITY-HORIZONS model was significantly lower than those of the CRUSADE and ACTION scores for the prediction of TIMI serious bleeding in overall patients (compared with CRUSADE, z = 3.83, P = 0.02; compared with ACTION, z = 3.51, P = 0.03); in NSTE-ACS patients (compared with CRUSADE, z = 2.37, P = 0.01; compared with ACTION, z = 2.11, P = 0.04), and in STEMI patients (compared with CRUSADE, z = 2.6.77, P = 0.02; compared with ACTION, z = 7.91, P = 0.002). No differences were observed when the CRUSADE and ACTION models were compared to each other, regardless of overall patients (z = 0.68, P = 0.31) and both of ACS types (NSTE-ACS, z = 0.52, P = 0.60), and STEMI patients (z = 0.36, P = 0.74). However, the three risk scores all overestimated the absolute major bleeding risk in each risk stratification in our study. For example, the predicted rate of CRUSADE score at high risk stratification was 11.9% vs. an actual rate of 5.3%.ConclusionsThe CRUSADE and ACTION scores had a greater calibration and discrimination for in-hospital major bleeding compared with the ACUITY-HORIZONS score in Chinese patients with ACS undergoing PCI. However, they all overestimated the bleeding risk rate for Chinese populations. Calibration of these risk scores would be useful for the generalization in Chinese populations.

Prognostic Utility of Bleeding Risk Scores in Acute Coronary Syndrome: A Meta-Analysis

Background: Bleeding is a common and frequently devastating complication in acute coronary syndrome (ACS), and critical to evaluate in the current era of ACS management involving invasive strategies and potent antithrombotics. Risk models remain under-utilised in this setting but may guide therapy, and we compared their performance for predicting bleeding in ACS patients in this meta-analysis. Methods: Medline, Embase, Cochrane and Scopus were searched for relevant articles from 1980 to 30 June 2016 assessing external validation of ACS bleeding risk scores. Two authors independently reviewed the searched studies for inclusion for pooled analyses with random effects models. Results: Amongst 1662 articles searched, 62 full-texts were reviewed and 20 studies with 22,256 patients included for analyses. C-statistics (95% confidence interval)/number of studies for predicting major bleeding for each risk model were CRUSADE 0.713 (0.659 - 0.767)/14, ACUITY 0.702 (0.557 - 0.847)/4, Mehran 0.743 (0.719 - 0.767)/4, ACTION 0.767 (0.737 - 0.797)/3, HASBLED 0.636 (0.460 - 0.812)/3, GRACE 0.689 (0.473 - 0.905)/2 and CHA2DS2-VASc 0.580 (0.492 - 0.667)/2 respectively. Only the CRUSADE score had subgroup analyses in at least 2 studies, and it performed better in STEMI vs NSTEMI (c = 0.791 vs 0.747), radial vs femoral (c = 0.826 vs 0.734) and invasive vs non-invasive strategy (c = 0.750 vs 0.625). Heterogeneity of bleeding definitions and paucity of literature of models except CRUSADE were important limitations. Conclusions: The ACS bleeding-specific scores had moderate discrimination and performed better than other scores. The CRUSADE score was the most widely studied and validated, performing better in STEMI, radial access and invasive strategy subgroups.

Meta-Analysis of Risk Scores to Predict Bleeding in Acute Coronary Syndrome

Background: Bleeding is a common and frequently devastating complication in acute coronary syndrome (ACS), and critical to evaluate in the current era of ACS management involving invasive strategies and potent antithrombotics. Risk models remain under-utilised in this setting but may guide therapy, and we compared their performance for predicting bleeding in ACS patients in this meta-analysis. Methods: Medline, Embase, Cochrane and Scopus were searched for relevant articles from 1980 to 30 June 2016 assessing external validation of ACS bleeding risk scores. Two authors independently reviewed the searched studies for inclusion for pooled analyses with random effects models. Results: Amongst 1,662 articles searched, 62 full-texts were reviewed and 20 studies with 22,256 patients included for analyses. C-statistics (95% confidence interval)/number of studies for predicting major bleeding for each risk model were CRUSADE 0.713 (0.659 - 0.767)/14, ACUITY 0.702 (0.557 - 0.847)/4, Mehran 0.743 (0.719 - 0.767)/4, ACTION 0.767 (0.737 - 0.797)/3, HASBLED 0.636 (0.460 - 0.812)/3, GRACE 0.689 (0.473 - 0.905)/2 and CHA2DS2-VASc 0.580 (0.492 - 0.667)/2 respectively. Only the CRUSADE score had subgroup analyses in at least 2 studies, and it performed better in STEMI vs NSTEMI (c = 0.791 vs 0.747), radial vs femoral (c = 0.826 vs 0.734) and invasive vs non-invasive strategy (c = 0.750 vs 0.625). Heterogeneity of bleeding definitions and paucity of literature of models except CRUSADE were important limitations. Conclusions: The ACS bleeding-specific scores had moderate discrimination and performed better than other scores. The CRUSADE score was the most widely studied and validated, performing better in STEMI, radial access and invasive strategy subgroups.

Contemporary Antiplatelet Therapy in Acute Coronary Syndromes: Are There Differences in Outcomes and Complications Between Clopidogrel and Ticagrelor?

Background: We studied clinical outcomes and discontinuation rates in a “real world” population presenting with myocardial infarction treated with ticagrelor or clopidogrel. Methods: Between January 2012 and May 2015, 992 patients with acute myocardial infarction undergoing invasive management and adequately pre-treated with dual antiplatelet therapy were prospectively enrolled. Baseline characteristics, in-hospital outcomes and 1-year outcomes were collected. Results: Patients treated with ticagrelor were younger and less likely to be diabetic, have a previous myocardial infarction, or present with a STEMI (all p < 0.05). Those treated with ticagrelor also had lower CRUSADE (20 ± 9.4 vs. 23 ± 10.1, p < 0.0001) and GRACE (119 ± 28 vs. 126 ± 32, p = 0.002) scores. Non-CABG related TIMI major and minor bleeding occurred at similar rates in those treated with ticagrelor and clopidogrel. Rates of drug discontinuation in those treated with ticagrelor and clopidogrel were similar in-hospital (20.2% vs. 16.2%, p = 0.18) and between discharge and 1 year (29.9% vs. 27.9%, p = 0.63). Discontinuation due to bleeding was infrequent and occurred at similar rates in those treated with ticagrelor and clopidogrel (2.8% vs. 1.4%, p = 0.18). However, discontinuation due to dyspnoea, (3.3% vs. 0%, p < 0.0001) and discontinuation due to any possible drug related adverse event (9.3% vs. 2.2%, p = 0.0001) was more common in those treated with ticagrelor compared to clopidogrel. Conclusion: Ticagrelor is paradoxically being used in patients with lower risk rather than those most likely to benefit. Ticagrelor was associated with similar rates of bleeding but higher discontinuation rates due to adverse effects compared to clopidogrel.

Evaluating the Ability of Bleeding Risk Scores and Platelet Reactivity to Predict Bleeding Risk in Those Presenting with Myocardial Infarction

Background: Bleeding following myocardial infarction (MI) has been consistently linked to mortality. Being able to identify those at risk of bleeding is therefore important. We assessed bleeding and examined the ability of the CRUSADE and ACTION bleeding risk scores and platelet reactivity to predict bleeding at one year. Methods: We prospectively enrolled 1000 MI patients and examined the primary endpoint of non-CABG TIMI major or minor bleeding at one year. Residual platelet reactivity was measured using the Multiplate analyser. Univariate and multivariate analyses were performed to identify predictors of bleeding. The accuracy of bleeding risk scores and platelet reactivity were evaluated using receiver operator characteristic curve analyses. Results: The primary endpoint occurred in 133 (13.3%) patients, consisting of 7 (5.3%) TIMI major and 126 (94.7%) TIMI minor bleeds. Forty-six (35%) bleeding events occurred in-hospital and 87 (65%) out-of-hospital. Age, female gender, hypertension, renal dysfunction, PCI and DAPT at discharge were predictive of bleeding events. Only female gender and PCI were independent predictors of bleeding. CRUSADE (AUC = 0.610, p = 0.01) and ACTION (AUC = 0.568, p = 0.05) were modestly predictive of in-hospital bleeding but platelet reactivity (AUC = 0.5, p = 0.99) was not. Neither CRUSADE (AUC = 0.487, p = 0.65), ACTION (AUC = 0.486, p = 0.66) nor platelet reactivity (AUC = 0.506, p = 0.86) were predictive of out-of-hospital bleeding or overall bleeding at one year (AUC = 0.533, p = 0.23; AUC = 0.522, p = 0.41 and AUC = 0.504, p = 0.88 respectively). Conclusion: Most bleeding events were TIMI minor and occurred out-of-hospital. Current tools were not predictive of bleeding at 1 year. This suggests that we need better tools to identify patients most likely to experience bleeding.

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.

Frailty predicts major bleeding within 30 days in elderly patients with Acute Coronary Syndrome

ObjectiveBleeding in ACS patients is an independent marker of adverse outcomes. Its prognostic impact is even worse in elderly population. Current bleeding risk scores include chronological age but do not consider biologic vulnerability. No studies have assessed the effect of frailty on major bleeding. The aim of this study is to determine whether frailty status increases bleeding risk in patients with ACS. MethodsThis prospective and observational study included patients aged ≥75years admitted due to type 1 myocardial infarction. Exclusion criteria were severe cognitive impairment, impossibility to measure handgrip strength, cardiogenic shock and limited life expectancy due to oncologic diseases. The primary endpoint was 30-day major bleeding defined as a decrease of ≥3g/dl of haemoglobin or need of transfusion. ResultsA total of 190 patients were included. Frail patients (72, 37.9%) were older, with higher comorbidity features and with a higher CRUSADE score at admission. On univariate analysis, frailty predicted major bleeding during 30-day follow-up despite less frequent use of a P2Y12 inhibitor (66.2% vs 83.6%, p=0.007) and decreased catheterisation rate (69.4% vs 94.1%, p<0.001). Major bleeding was associated with increased all-cause mortality at day 30 (18.2% vs 2.5%, p<0.001). On multivariate analysis, frailty was an independent predictor for major bleeding. ConclusionFrailty phenotype, as a marker of biological vulnerability, is an independent predictor of major bleeding in elderly patients with ACS. Frailty can play an important role in bleeding risk stratification and objective indices should be integrated into routine initial evaluation of these patients.

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.

Frailty is a short-term prognostic marker in acute coronary syndrome of elderly patients.

Frailty is a biological condition that reflects a state of decreased physiological reserve and vulnerability to stressors. The role of frailty in acute coronary syndrome patients has not been fully explored. Our study aims to assess the prevalence of frailty and its impact on in-hospital adverse outcomes of patients aged ⩾75 years admitted for acute coronary syndrome. This prospective, observational study included patients aged ⩾75 years admitted due to type 1 myocardial infarction in four tertiary hospitals. Frailty was assessed by the SHARE-FI index. The primary endpoint was the combination of in-hospital death or non-fatal myocardial (re)infarction. Secondary endpoints included the assessment of individual rates of (re)infarction, mortality, stroke, major bleeding and the combination of in-hospital death, (re)infarction and mortality. A total of 202 patients were analysed. Frail patients (n=71, 35.1%) were older, more often women, had higher rates of comorbidities, and a higher risk profile according to GRACE, TIMI and CRUSADE scores at admission. The primary endpoint was significantly more frequent among frail patients (9.9% vs. 1.5%; P=0.006), as well as the combination of death, myocardial infarction and stroke (11.3% vs. 1.5%; P=0.002), driven mainly by a higher mortality rate (8.5% vs 0.8%; P=0.004). On multivariate analysis, frailty phenotype was an independent predictor of major adverse cardiac events (odds ratio 7.13; 95% confidence interval 1.43-35.42). Over one third of elderly patients with high-risk acute coronary syndrome are frail. Frailty phenotype is an important and independent prognostic marker in these patients.

CRUSADE bleeding score as a predictor of bleeding events in patients with acute coronary syndrome in Zagazig University Hospital

AimTo examine the value of CRUSADE bleeding score in predicting bleeding events in our local patients with acute coronary syndrome (ACS) in Zagazig University Hospitals. MethodsOur study included 240 patients with ACS. They underwent history and clinical examination; 12-lead electrocardiography; echocardiography; troponin I, hematocrit value; estimated glomerular filtration rate (eGFR); application of CRUSADE score; and follow-up of the hospital stay and documentations of events. Patients were classified into two groups: Group I: patients with major bleeding, and Group II: patients without major bleeding. ResultsPatients with major bleeding were significantly older, with more diabetic and hypertensive patients, more prior vascular disease, heart failure, and less patients with unstable angina, higher heart rate and systolic blood, lower eGFR, and higher CRUSADE risk score.CRUSADE bleeding score was the strongest predictor of major bleeding. Sensitivity of CRUSADE score ≥33 in prediction of major bleeding in the whole study group was 80%, specificity was 73.4%, positive predictive value was 26.9%, negative predictive value was 96.9%, overall accuracy was 74.1%. Sensitivity of CRUSADE score ≥38.5 in prediction of major bleeding in the STEMI patients was 70%, specificity was 84.8%, positive predictive value was 50%, negative predictive value was 92.9%, and overall accuracy was 82.1%. ConclusionCRUSADE score is a good predictor for major bleeding in Egyptian patients with ACS. It is applicable in UA/NSTEMI as well as in STEMI patients and in women as well as in men.

Predictive performance of HAS-BLED risk score for long-term survival in patients with non-ST elevated myocardial infarction without atrial fibrillation

BackgroundPredictive value of the Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly, Drugs or alcohol use (HAS-BLED) score for clinical outcomes has been investigated in patients with and without atrial fibrillation. Many factors in the HAS-BLED model have been reported to be prognostic predictors in patients with post-myocardial infarction (MI). However, few studies have investigated the predictive value of HAS-BLED score on long-term survival in patients with post-MI. MethodsA total of 617 patients with non-ST elevation MI (NSTEMI) without atrial fibrillation were enrolled. The Thrombolysis In Myocardial Infarction (TIMI), Global Registry of Acute Coronary Events (GRACE), Can Rapid Risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE), and HAS-BLED risk scores were calculated for each patient. ResultsThe C-statistics of TIMI, GRACE, CRUSADE, and HAS-BLED scores for 3-year survival were 0.658, 0.749, 0.756, and 0.765, respectively. For 3-year survival prediction, GRACE, CRUSADE, and HAS-BLED scores, respectively demonstrated superior performance than TIMI score and there was no significant difference between these three scores (GRACE vs. TIMI: z=1.615, p=0.027; CRUSADE vs. TIMI: z=1.371, p=0.043; HAS-BLED vs. TIMI: z=1.899, p=0.014; CRUSADE vs. GRACE: z=0.078, p=0.234; HAS-BLED vs. GRACE: z=0.435, p=0.166; HAS-BLED vs. CRUSADE: z=0.353, p=0.181). Multivariate analysis showed left ventricular ejection fraction <40%, old age, stroke history, bleeding history, and abnormal renal and liver function were independent predictors for 3-year mortality. ConclusionsHAS-BLED scoring system is similar to the GRACE and CRUSADE systems but better than TIMI system to predict long-term survival outcomes in patients with NSTEMI without atrial fibrillation. However, HAS-BLED score is easier to calculate than GRACE and CRUSADE scores.