HAS-BLED Score Predicts the Risk of Major Bleeding in Chronic Anticoagulation after Lower Limb Surgical Revascularization

Validation of prediction tools for GI bleeding in patients on dual anti-platelet therapy after percutaneous coronary intervention

BACKGROUND AND AIMS

The management of dual anti-platelet therapy after percutaneous coronary intervention (PCI) and GI bleeding (GIB) remains a clinical dilemma. We sought to identify predictors of GIB and recurrent bleeding and to determine whether recurrent bleeding increases the risk of major adverse cardiovascular events (MACEs).

METHODS

In this single-center retrospective study, patients undergoing PCI were identified. The primary and secondary endpoints were GIB at 180 days and recurrent bleeding or MACE at 365 days. Logistic regression was used to identify predictors of GIB and recurrent bleeding. Cox proportional hazards modeling was used to determine whether recurrent bleeding can predict a MACE.

RESULTS

Five hundred thirty-six patients were included. On multivariable analysis, PCI for acute coronary syndrome was associated with a 95% increased odds of GIB (P < .001). The P2Y12 inhibitor was continued in >90% of patients, which trended toward significance for recurrent bleeding (P < .10). The HAS-BLED score (Hypertension, Abnormal renal and liver function, Stroke, Bleeding tendency or predisposition, Labile INRs, Elderly, Drugs), including a labile international normalized ratio and prior major bleeding, was strongly associated with recurrent bleeding (P ≤ .009). Recurrent bleeding was associated with a 115% increased risk of MACEs (P = .02). We derived a novel risk score, named the SIGE score ([S]TEMI at PCI, having a labile [I]NR at PCI, index [G]IB within 180 days of PCI, and previous precatheterization [E]ndoscopy within 6 months), to predict recurrent bleeding at 365 days with a high predictive accuracy (area under the curve, .773; 95% confidence interval, .702-.845).

CONCLUSIONS

The SIGE score may help to predict recurrent bleeding, which was shown to be associated with an increased risk of MACEs. Further external validation is needed.

Preventing Lower Limb Graft Thrombosis after Infrainguinal Arterial Bypass Surgery with Antithrombotic Agents (PATENT Study): An International Expert Based Delphi Consensus

(1) Background: High-level evidence on antithrombotic therapy after infrainguinal arterial bypass surgery in specific clinical scenarios is lacking. (2) Methods: A modified Delphi procedure was used to develop consensus statements. Experts voted on antithrombotic treatment regimens for three types of infrainguinal arterial bypass procedures: above-the-knee popliteal artery; below-the-knee popliteal artery; and distal, using vein, prosthetic, or biological grafts. The treatment regimens for these nine procedures were then voted on in three clinical scenarios: isolated PAOD, atrial fibrillation, and recent coronary intervention. (3) Results: The survey was conducted with 28 experts from 15 European countries, resulting in consensus statements on 25/27 scenarios. Experts recommended single antiplatelet therapy after above-the-knee popliteal artery bypasses regardless of the graft material used. For below-the-knee popliteal artery bypasses, experts suggested combining single antiplatelet therapy with low-dose rivaroxaban if the graft material used was autologous or biological. They did not recommend switching to triple therapy for patients on oral anticoagulants for atrial fibrillation or dual antiplatelet therapy in any scenario. (4) Conclusions: Great inconsistency in the antithrombotic therapy administered was found in this study. This consensus offers guidance for scenarios that are not covered in the current ESVS guidelines but must be interpreted within its limitations.

Empiric use of anticoagulation in hospitalized patients with COVID-19: a propensity score-matched study of risks and benefits

Background

Hospitalized patients with COVID-19 demonstrate a higher risk of developing thromboembolism. Anticoagulation (AC) has been proposed for high-risk patients, even without confirmed thromboembolism. However, benefits and risks of AC are not well assessed due to insufficient clinical data. We performed a retrospective analysis of outcomes from AC in a large population of COVID-19 patients.

Methods

We retrospectively reviewed 1189 patients hospitalized for COVID-19 between March 5 and May 15, 2020, with primary outcomes of mortality, invasive mechanical ventilation, and major bleeding. Patients who received therapeutic AC for known indications were excluded. Propensity score matching of baseline characteristics and admission parameters was performed to minimize bias between cohorts.

Results

The analysis cohort included 973 patients. Forty-four patients who received therapeutic AC for confirmed thromboembolic events and atrial fibrillation were excluded. After propensity score matching, 133 patients received empiric therapeutic AC while 215 received low dose prophylactic AC. Overall, there was no difference in the rate of invasive mechanical ventilation (73.7% versus 65.6%, p = 0.133) or mortality (60.2% versus 60.9%, p = 0.885). However, among patients requiring invasive mechanical ventilation, empiric therapeutic AC was an independent predictor of lower mortality (hazard ratio [HR] 0.476, 95% confidence interval [CI] 0.345–0.657, p < 0.001) with longer median survival (14 days vs 8 days, p < 0.001), but these associations were not observed in the overall cohort (p = 0.063). Additionally, no significant difference in mortality was found between patients receiving empiric therapeutic AC versus prophylactic AC in various subgroups with different D-dimer level cutoffs. Patients who received therapeutic AC showed a higher incidence of major bleeding (13.8% vs 3.9%, p < 0.001). Furthermore, patients with a HAS-BLED score of ≥2 had a higher risk of mortality (HR 1.482, 95% CI 1.110–1.980, p = 0.008), while those with a score of ≥3 had a higher risk of major bleeding (Odds ratio: 1.883, CI: 1.114–3.729, p = 0.016).

Conclusion

Empiric use of therapeutic AC conferred survival benefit to patients requiring invasive mechanical ventilation, but did not show benefit in non-critically ill patients hospitalized for COVID-19. Careful bleeding risk estimation should be pursued before considering escalation of AC intensity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40364-021-00283-y.

Selective Use of Anticoagulation or Dual Antiplatelet Therapy for Patients with Extra-anatomic Bypasses

BACKGROUND

The benefit of long-term anticoagulation or dual antiplatelet therapy (DAPT) for patients with extra-anatomic bypasses to the lower extremity remains poorly defined. Our study analyzed the real-world use of antithrombotic therapy in patients with extra-anatomic bypass grafts to the lower extremity and compared graft and patient outcomes by antithrombotic regimen.

METHODS

We studied patients who underwent axillofemoral or femoral-femoral bypass within the Vascular Quality Initiative with one-year follow-up data. Primary exposures were anticoagulation and DAPT, at the time of index procedure and one-year follow-up. Primary outcomes were major adverse limb events (MALE) defined as reintervention or above-ankle amputation, and primary patency. Secondary outcomes included perioperative blood transfusion requirements and the need for reoperation specifically for bleeding. We analyzed outcomes using the Kaplan-Meier estimation and examined factors associated with choice of antithrombotic therapy via logistic regression.

RESULTS

Our cohort included 2,760 patients (axillofemoral bypass, n = 857; femoral-femoral bypass, n = 1,903) across 168 centers from 2009 to 2018. Mean age was 66.5 ± 10.5 years and 59% were male. Patients were infrequently prescribed long-term anticoagulation (19%) or DAPT (22%). One-year primary patency was 86% and was similar by anticoagulation (log-rank P = 0.12) and DAPT status (log-rank P = 0.26). Freedom from MALE was 87% at 1 year and was slightly inferior for patients on anticoagulation (88 vs. 83%, log-rank P = 0.001) but was similar by DAPT (log-rank P = 0.19). Transfusion was more common in patients who were anticoagulated than those who were not (30 vs. 25%, P < 0.01), but there was no increase in reoperation because of bleeding (anticoagulation 0.8 vs. 0.8, P = 0.98). Anticoagulation was more commonly prescribed according to disease severity, such as rest pain (adjusted odds ratio (OR): 1.6 (95% confidence interval (CI): 1.20-2.20), tissue loss (OR: 1.9, CI: 1.28-2.73), or acute limb ischemia (OR: 1.9, CI: 1.35-2.71) or prior bypass graft (OR: 2.6, CI: 2.07-3.35). Patients were more commonly prescribed DAPT according to comorbidities, including hypertension (OR: 1.4, CI: 1.04-1.94) and coronary artery disease (OR: 1.6, CI 1.26-1.95).

CONCLUSIONS

Antithrombotics are selectively used in patients with extra-anatomic bypass to the lower extremity, the selection of which appears associated with disease severity for anticoagulants and patient comorbidities for DAPT. Primary patency and MALE rates are similar with focused utilization of anticoagulants or DAPT. Blood transfusions are more common among patients on antithrombotics without a difference in the need for reoperation for bleeding.