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Doomun I, Doomun D, Schukraft S, Arroyo D, Cook ST, Huwyler T, Goy JJ, Stauffer JC, Togni M, Puricel S, Cook S. Predictive Value of HAS-BLED and HEMORR2HAGES Bleeding Risk Scores After Percutaneous Coronary Intervention. Tex Heart Inst J 2024; 51:e238267. [PMID: 38982874 PMCID: PMC11233982 DOI: 10.14503/thij-23-8267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2024]
Abstract
BACKGROUND Various scoring systems have been developed to assess the risk of bleeding in medical settings. HAS-BLED and HEMORR2HAGES risk scores are commonly used to estimate bleeding risk in patients receiving anticoagulation for atrial fibrillation, but data on their predictive value in patients undergoing percutaneous coronary intervention (PCI) are limited. METHODS This study evaluated and compared the predictive abilities of the HAS-BLED and HEMORR2HAGES bleeding risk scores in all-comer patients undergoing PCI. The PARIS score, specifically designed for patients undergoing PCI, was used as a comparator. The scores were calculated at baseline and compared with the occurrence of events during a 2-year clinical follow-up period. Between 2015 and 2017, all consecutive patients undergoing PCI we re prospectively enrolled and divided into risk tertiles based on bleeding risk scores. The primary end points were hierarchical major bleeding events, defined by Bleeding Academic Research Consortium types 3 through 5, and patient-oriented composite end points according to Bleeding Academic Research Consortium classification, which were assessed during the 2-year follow-up period. RESULTS A total of 1,080 patients completed the follow-up period. Two years after index, 189 patients (17.5%) had experienced any bleeding, with 48 events (4.4%) classified as Bleeding Academic Research Consortium types 3 to 5. All bleeding risk scores showed statistically significant predictive ability for bleeding events. The HEMORR2HAGES score (C statistic, 0.73) was more effective than the HAS-BLED score (C statistic, 0.66; P = .07) and the PARIS score (C statistic, 0.66; P = .06) in predicting risk of major bleeding. Patients in high-risk bleeding groups also experienced a higher incidence of patient-oriented composite end points. CONCLUSIONS The HEMORR2HAGES, HAS-BLED, and PARIS risk scores exhibited good predictive abilities for bleeding events following PCI. Patients at high risk of bleeding also demonstrated increased ischemic risk and higher mortality during the 2-year follow-up period.
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Affiliation(s)
- Ianis Doomun
- Department of Cardiology, University and Hospital Fribourg, Fribourg, Switzerland
| | - Daphné Doomun
- Department of Cardiology, University and Hospital Fribourg, Fribourg, Switzerland
| | - Sara Schukraft
- Department of Cardiology, University and Hospital Fribourg, Fribourg, Switzerland
| | - Diego Arroyo
- Department of Cardiology, University and Hospital Fribourg, Fribourg, Switzerland
| | - Selma T. Cook
- Department of Cardiology, University and Hospital Fribourg, Fribourg, Switzerland
| | - Tibor Huwyler
- Department of Cardiology, University and Hospital Fribourg, Fribourg, Switzerland
| | - Jean-Jacques Goy
- Department of Cardiology, University and Hospital Fribourg, Fribourg, Switzerland
| | | | - Mario Togni
- Department of Cardiology, University and Hospital Fribourg, Fribourg, Switzerland
| | - Serban Puricel
- Department of Cardiology, University and Hospital Fribourg, Fribourg, Switzerland
| | - Stéphane Cook
- Department of Cardiology, University and Hospital Fribourg, Fribourg, Switzerland
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Yoon HY, Song TJ, Yee J, Park J, Gwak HS. Association between Genetic Polymorphisms and Bleeding in Patients on Direct Oral Anticoagulants. Pharmaceutics 2022; 14:pharmaceutics14091889. [PMID: 36145636 PMCID: PMC9501033 DOI: 10.3390/pharmaceutics14091889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 08/26/2022] [Accepted: 09/03/2022] [Indexed: 11/16/2022] Open
Abstract
Objectives: The purpose of our study is to investigate the effects of apolipoprotein B (APOB) and APOE gene polymorphisms on bleeding complications in patients receiving direct oral anticoagulants (DOACs). Methods: A total of 16 single nucleotide polymorphisms (SNPs) in 468 patients were genotyped. Six SNPs of ABCB1 (rs3842, rs1045642, rs2032582, rs1128503, rs3213619, and rs3747802), one SNP of CYP3A5 (rs776746), seven SNPs of APOB (rs1042034, rs2163204, rs693, rs679899, rs13306194, rs13306198, and rs1367117), and two SNPs of APOE (rs429358 and rs7412) were analyzed by a TaqMan genotyping assay. Multivariable logistic regression analysis with selected variables was performed for the construction of a risk scoring system. Two risk scoring systems were compared (demographic factors only vs. demographic factors and genetic factors). Results: In the multivariable analyses, two models were constructed; only demographic factors were included in Model I and both demographic factors and genetic factors in Model II. Rivaroxaban and anemia showed significant association with bleeding in both models. Additionally, ABCB1 rs3842 variant homozygote carriers (CC) and APOB rs13306198 variant allele carriers (AG, AA) had a higher risk of bleeding risk compared with that of wild-type allele carriers (TT, TC) and wild-type homozygote carriers (GG), respectively. Whereas the area under the receiver operating characteristic curve (AUROC) value using demographic factors only was 0.65 (95% confidence interval (CI): 0.56–0.74), the AUROC increased to 0.72 by adding genetic factors (95% CI: 0.65–0.80). The predicted bleeding risks of bleeding in patients with 0, 1, 2, 3, 4, 5, 6, 7 and 8 points from the logistic regression curve were 0.8%, 2.0%, 5.4%, 5.2%, 12.5%, 26.9%, 47.0%, 64.3% and 82.3%, respectively. Conclusions: The study results can be used for enhancing individualized treatment strategies in patients taking DOACs, helping clinicians predict the bleeding risk.
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Affiliation(s)
- Ha-Young Yoon
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, 52 Ewhayeodae-gil, Seodaemun-gu, Seoul 03760, Korea
| | - Tae-Jin Song
- Department of Neurology, Ewha Womans University Seoul Hospital, Ewha Womans University College of Medicine, Seoul 07804, Korea
| | - Jeong Yee
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, 52 Ewhayeodae-gil, Seodaemun-gu, Seoul 03760, Korea
| | - Junbeom Park
- Division of Cardiology, Department of Internal Medicine, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Seoul 07985, Korea
- Correspondence: (J.P.); (H.-S.G.)
| | - Hye-Sun Gwak
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, 52 Ewhayeodae-gil, Seodaemun-gu, Seoul 03760, Korea
- Correspondence: (J.P.); (H.-S.G.)
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Lyu SQ, Zhu J, Wang J, Wu S, Zhang H, Shao XH, Yang YM. Predictive performance of different bleeding risk scores in patients with atrial fibrillation and acute coronary syndrome or undergoing percutaneous coronary intervention. Platelets 2022; 33:900-910. [PMID: 35103582 DOI: 10.1080/09537104.2021.2007870] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Si-Qi Lyu
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Jun Zhu
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Juan Wang
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Shuang Wu
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Han Zhang
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Xing-Hui Shao
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yan-Min Yang
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
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Lyu SQ, Zhu J, Wang J, Wu S, Zhang H, Shao XH, Yang YM. Validation of the Academic Research Consortium for High Bleeding Risk criteria in Chinese patients with atrial fibrillation and acute coronary syndrome or undergoing percutaneous coronary intervention. Thromb Res 2021; 209:16-22. [PMID: 34844044 DOI: 10.1016/j.thromres.2021.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 11/02/2021] [Accepted: 11/16/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND This study aims to validate the Academic Research Consortium for High Bleeding Risk (ARC-HBR) criteria in Chinese patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI) who received both oral anticoagulants (OAC) and antiplatelet therapy (APT). METHODS 930 consecutive patients with AF and ACS or undergoing PCI receiving both OAC and APT were recruited and followed up for 1 year. The primary endpoint was BARC type 3 or 5 bleeding. The secondary endpoints included BARC type 2, 3, or 5 bleeding, TIMI major bleeding, TIMI major or minor bleeding, and major adverse cardiovascular events (a composite of all-cause death, stroke, non-central nervous system embolism, myocardial infarction, definite or probable stent thrombosis, and target vessel revascularization). Cox regressions were performed to evaluate the association between the ARC-HBR score and outcomes. Discrimination was evaluated through analysis of the receiver operating characteristic (ROC) curves, net reclassification improvement (NRI), and integrated discrimination improvement (IDI). RESULTS Compared to patients with no HBR other than OAC, patients with HBR besides OAC tended to have more comorbidities and worse outcomes. The ARC-HBR score was significantly associated with the primary and secondary endpoints, both as a continuous variable and as a categorical variable. The ARC-HBR score performed better than the HAS-BLED score (c-statistic: 0.692 vs. 0.575, NRI = 0.313, IDI = 0.061) and the PRECISE-DAPT score (c-statistic: 0.692 vs. 0.616, NRI = 0.393, IDI = 0.049). CONCLUSIONS In patients with AF and ACS or undergoing PCI receiving both OAC and APT, the ARC-HBR score was a significant predictor of 1-year bleeding and ischemic endpoints. The ARC-HBR score performed better than the HAS-BLED score and the PRECISE-DAPT score in BARC type 3 or 5 bleeding prediction.
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Affiliation(s)
- Si-Qi Lyu
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, People's Republic of China
| | - Jun Zhu
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, People's Republic of China
| | - Juan Wang
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, People's Republic of China
| | - Shuang Wu
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, People's Republic of China
| | - Han Zhang
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, People's Republic of China
| | - Xing-Hui Shao
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, People's Republic of China
| | - Yan-Min Yang
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, People's Republic of China.
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5
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Arfat Y, Mittone G, Esposito R, Cantalupo B, DE Ferrari GM, Aldinucci M. A review of machine learning for cardiology. Minerva Cardiol Angiol 2021; 70:75-91. [PMID: 34338485 DOI: 10.23736/s2724-5683.21.05709-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This paper reviews recent cardiology literature and reports how Artificial Intelligence Tools (specifically, Machine Learning techniques) are being used by physicians in the field. Each technique is introduced with enough details to allow the understanding of how it works and its intent, but without delving into details that do not add immediate benefits and require expertise in the field. We specifically focus on the principal Machine Learning based risk scores used in cardiovascular research. After introducing them and summarizing their assumptions and biases, we discuss their merits and shortcomings. We report on how frequently they are adopted in the field and suggest why this is the case based on our expertise in Machine Learning. We complete the analysis by reviewing how corresponding statistical approaches compare with them. Finally, we discuss the main open issues in applying Machine Learning tools to cardiology tasks, also drafting possible future directions. Despite the growing interest in these tools, we argue that there are many still underutilized techniques: while Neural Networks are slowly being incorporated in cardiovascular research, other important techniques such as Semi-Supervised Learning and Federated Learning are still underutilized. The former would allow practitioners to harness the information contained in large datasets that are only partially labeled, while the latter would foster collaboration between institutions allowing building larger and better models.
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Affiliation(s)
- Yasir Arfat
- Computer Science Department, University of Turin, Turin, Italy -
| | | | | | | | - Gaetano M DE Ferrari
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, Turin, Italy.,Cardiology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Marco Aldinucci
- Computer Science Department, University of Turin, Turin, Italy
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Adam L, Feller M, Syrogiannouli L, Del-Giovane C, Donzé J, Baumgartner C, Segna D, Floriani C, Roten L, Fischer U, Aeschbacher S, Moschovitis G, Schläpfer J, Shah D, Amman P, Kobza R, Schwenkglenks M, Kühne M, Bonati LH, Beer J, Osswald S, Conen D, Aujesky D, Rodondi N. Novel bleeding risk score for patients with atrial fibrillation on oral anticoagulants, including direct oral anticoagulants. J Thromb Haemost 2021; 19:931-940. [PMID: 33501722 DOI: 10.1111/jth.15251] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 12/23/2020] [Accepted: 01/12/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Balancing 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. METHODS We 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. RESULTS We 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). CONCLUSION In this prospective cohort study of AF patients and predominantly DOAC users, we successfully derived a bleeding risk prediction model with good calibration and discrimination.
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Affiliation(s)
- Luise Adam
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Division of Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Martin Feller
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care (BIHAM, University of Bern, Bern, Switzerland
| | | | - Cinzia Del-Giovane
- Institute of Primary Health Care (BIHAM, University of Bern, Bern, Switzerland
| | - Jacques Donzé
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Medicine, Neuchâtel Hospital Network, Neuchâtel, Switzerland
- Department of Medicine, Division of General Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christine Baumgartner
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel Segna
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Gastroenterology and Hepatology, University Hospital of Zürich, Zurich, Switzerland
- Department of Gastroenterology, GZO Wetzikon, Wetzikon, Switzerland
| | - Carmen Floriani
- Institute of Primary Health Care (BIHAM, University of Bern, Bern, Switzerland
| | - Laurent Roten
- Department of Cardiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Stefanie Aeschbacher
- Cardiology Division, Department of Medicine, University Hospital Basel, Basel, Switzerland
- Cardiovascular Research Institute Basel, Basel, Switzerland
| | - Giorgio Moschovitis
- Division of Cardiology, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
| | - Jürg Schläpfer
- Department of Cardiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Dipen Shah
- Cardiology Service, Department of Medicine Specialities, University Hospital Geneva, Geneva, Switzerland
| | - Peter Amman
- Department of Cardiology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Richard Kobza
- Department of Cardiology, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Matthias Schwenkglenks
- Epidemiology, Biostatistics and Prevention Institute, University of Zürich, Zurich, Switzerland
| | - Michael Kühne
- Cardiology Division, Department of Medicine, University Hospital Basel, Basel, Switzerland
- Cardiovascular Research Institute Basel, Basel, Switzerland
| | - Leo H Bonati
- Neurology Division and Stroke Centre, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Jürg Beer
- Department of Medicine, Cantonal Hospital of Baden and Molecular Cardiology, University Hospital of Zurich, Zurich, Switzerland
| | - Stefan Osswald
- Cardiology Division, Department of Medicine, University Hospital Basel, Basel, Switzerland
- Cardiovascular Research Institute Basel, Basel, Switzerland
| | - David Conen
- Cardiovascular Research Institute Basel, Basel, Switzerland
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care (BIHAM, University of Bern, Bern, Switzerland
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Brazhnik VA, Minushkina LO, Erlikh AD, Kosmacheva ED, Chichkova MA, Khasanov NR, Zateyshchikov DA. Using the ORACLE Risk Score to Assess Hemorrhagic Risk in Patients with Acute Coronary Syndrome and Atrial Fibrillation. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2021. [DOI: 10.20996/1819-6446-2021-01-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- V. A. Brazhnik
- City clinical hospital №51;
Central State Medical Academy of Department of Presidential Affairs
| | - L. O. Minushkina
- Central State Medical Academy of Department of Presidential Affairs
| | | | | | - M. A. Chichkova
- Central State Medical Academy of Department of Presidential Affairs
| | | | - D. A. Zateyshchikov
- City clinical hospital №51;
Central State Medical Academy of Department of Presidential Affairs
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8
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Rozemeijer R, van Bezouwen WP, van Hemert ND, Damen JA, Koudstaal S, Stein M, Leenders GE, Timmers L, Kraaijeveld AO, Roes K, Agostoni P, Doevendans PA, Stella PR, Voskuil M. Direct comparison of predictive performance of PRECISE-DAPT versus PARIS versus CREDO-Kyoto: a subanalysis of the ReCre8 trial. Neth Heart J 2020; 29:201-214. [PMID: 32955703 PMCID: PMC7991032 DOI: 10.1007/s12471-020-01486-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Multiple scores have been proposed to guide risk stratification after percutaneous coronary intervention. This study assessed the performance of the PRECISE-DAPT, PARIS and CREDO-Kyoto risk scores to predict post-discharge ischaemic or bleeding events. Methods A total of 1491 patients treated with latest-generation drug-eluting stent implantation were evaluated. Risk scores for post-discharge ischaemic or bleeding events were calculated and directly compared. Prognostic performance of both risk scores was assessed with calibration, Harrell’s c‑statistics net reclassification index and decision curve analyses. Results Post-discharge ischaemic events occurred in 56 patients (3.8%) and post-discharge bleeding events in 34 patients (2.3%) within the first year after the invasive procedure. C‑statistics for the PARIS ischaemic risk score was marginal (0.59, 95% confidence interval (CI) 0.51–0.68), whereas the CREDO-Kyoto ischaemic risk score was moderate (0.68, 95% CI 0.60–0.75). With regard to post-discharge bleeding events, CREDO-Kyoto displayed moderate discrimination (c-statistic 0.67, 95% CI 0.56–0.77), whereas PRECISE-DAPT (0.59, 95% CI 0.48–0.69) and PARIS (0.55, 95% CI 0.44–0.65) had a marginal discriminative capacity. Net reclassification index and decision curve analysis favoured CREDO-Kyoto-derived bleeding risk assessment. Conclusion In this contemporary all-comer population, PARIS and PRECISE-DAPT risk scores were not resilient to independent testing for post-discharge bleeding events. CREDO-Kyoto-derived risk stratification was associated with a moderate predictive capability for post-discharge ischaemic or bleeding events. Future studies are warranted to improve risk stratification with more focus on robustness and rigorous testing. Electronic supplementary material The online version of this article (10.1007/s12471-020-01486-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- R Rozemeijer
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - W P van Bezouwen
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - N D van Hemert
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J A Damen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - S Koudstaal
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands.,Farr Institute of Health Informatics, University College London, London, UK
| | - M Stein
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Cardiology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - G E Leenders
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - L Timmers
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands.,St. Antonius Hospital, Nieuwegein, The Netherlands
| | - A O Kraaijeveld
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - K Roes
- Department of Biostatistics and Research Support, University Medical Center Utrecht, Utrecht, The Netherlands
| | - P Agostoni
- Department of Cardiology, Hartcentrum, Ziekenhuis Netwerk Antwerpen Middelheim, Antwerp, Belgium
| | - P A Doevendans
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands.,Netherlands Heart Institute, Utrecht, The Netherlands.,Central Military Hospital, Utrecht, The Netherlands
| | - P R Stella
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M Voskuil
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
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9
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Krivosheeva EN, Panchenko EP, Kropacheva ES, Dobrovolsky AB, Titaeva EV, Mironov VM, Samko AN. Prediction-Determining Outcomes and Their Predictors in Atrial Fibrillation Patients Receiving Multicomponent Antithrombotic Therapy in Real Clinical Practice. ACTA ACUST UNITED AC 2020; 60:33-45. [PMID: 33155957 DOI: 10.18087/cardio.2020.8.n1123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/01/2020] [Accepted: 06/30/2020] [Indexed: 11/18/2022]
Abstract
Aim Searching for clinical, angiographic, and biochemical predictors of cardiovascular complications (CVC) and hemorrhagic complications in patients with atrial fibrillation (AF) receiving a multicomponent antithrombotic therapy (MAT) for an elective percutaneous coronary intervention (PCI). Patients with ischemic heart disease (IHD) and AF who require MAT for PCI are at a high risk of thrombotic complications (stroke, systemic embolism, coronary events) and hemorrhage. This warrants searching for new risk factors determining prediction of the outcome.Materials and methods This study included 207 patients (146 males aged 70.1±8.3 years) with IHD and AF who received direct oral anticoagulants (DOAC) as a part of their MAT therapy. Median duration of the follow-up was 12 [8.0; 12.0] months. The efficacy endpoint was a sum of CVCs combining cardiovascular death, ischemic stroke, venous thromboembolic complications, acute coronary syndrome (ACS), and requirement for an unscheduled PCI. "Coronary events", including ACS and requirement for an unscheduled PCI were analyzed separately. The safety endpoint was BARC type 2-5 bleeding. Upon admission, biomarkers (growth-differentiation factor 15 (GDF-15), D-dimer, thrombin-activated fibrinolysis inhibitor (TAFI), and plasminogen activator inhibitor-1 (PAI-1)) were measured for all patients. Searching for prognostically significant indexes was performed with the Cox proportional hazards regression.Results Incidence of all CVCs was 16.4 %. Independent predictors of CVC included the DOAC treatment at a reduced dose (odds ratio (OR) 2.5 at 95 % confidence interval (CI) 1.02-6.15; p=0.0454), GDF-15 >1191 pg /ml (OR 3.76 at 95 % CI, 1.26-11.18; p=0.0172), PAI-1 >13.2 U/ml (OR 2.67 at 95 % CI, 1.13-6,26; p=0.0245). Incidence of coronary complications was 9.2 %. Independent predictors of coronary complications included a SYNTAX index >26.5 (OR 4.5 at 95 % CI, 1.45-13.60; p=0.0090), PCI for chronic coronary occlusion (OR 3.21 at 95 % CI, 1.10-9.33; p=0.0326), a GDF-15 >1191 pg/ml (ОR 4.70 at 95 % CI, 1.32-16.81; p=0.0172). Incidence of BARC type 2-5 bleeding was 26.1 %. The only independent predictor for hemorrhage complications was the total PRECISE-DAPT score >30 (ОR 3.22; 95 % CI, 1.89-5.51; р<0.0001).Conclusion Three independent predictors of CVC were identified for patients with IHD and AF treated with MAT following an elective PCI: treatment with a reduced dose of DOAC, GDF-15 >1191 pg /ml, and PAI-1>13.2 U/ml. Independent predictors of coronary complications included a SYNTAX index >26.5, PCI for chronic coronary occlusion, and GDF-15 >1191 pg/ml. The factor associated with a risk of bleeding was the total PRECISE-DAPT score >30.
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Affiliation(s)
- E N Krivosheeva
- National medical research center of cardiology of the Ministry of healthcare of the Russian Federation, Moscow
| | - E P Panchenko
- National medical research center of cardiology of the Ministry of healthcare of the Russian Federation, Moscow
| | - E S Kropacheva
- National medical research center of cardiology of the Ministry of healthcare of the Russian Federation, Moscow
| | - A B Dobrovolsky
- National medical research center of cardiology of the Ministry of healthcare of the Russian Federation, Moscow
| | - E V Titaeva
- National medical research center of cardiology of the Ministry of healthcare of the Russian Federation, Moscow
| | - V M Mironov
- National medical research center of cardiology of the Ministry of healthcare of the Russian Federation, Moscow
| | - A N Samko
- National medical research center of cardiology of the Ministry of healthcare of the Russian Federation, Moscow
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10
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Nakamura M, Yamashita T, Hayakawa A, Matsumoto T, Takita A, Hasegawa C, Uchino K, Sekine T, Iizuka T, Tanabe H, Kogure S. Bleeding risks associated with anticoagulant therapies after percutaneous coronary intervention in Japanese patients with ischemic heart disease complicated by atrial fibrillation: A comparative study. J Cardiol 2020; 77:186-194. [PMID: 32943280 DOI: 10.1016/j.jjcc.2020.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 07/20/2020] [Accepted: 08/11/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Current guidelines recommend early termination of triple therapy and the use of direct oral anticoagulants (DOAC) for non-valvular atrial fibrillation (NVAF) patients who undergo percutaneous coronary intervention (PCI), due to safety concerns. However, to date, real-world medication usage and safety outcomes (specifically bleeding) in NVAF patients with stent implantation have not been well assessed. METHODS This was a retrospective, observational, medical database cohort study in Japanese ischemic heart disease (IHD) patients with NVAF who underwent PCI between 2012 and 2017. The primary outcome was clinically relevant bleeding; secondary outcomes included individual bleeding events. A multivariate analysis was conducted to identify risk factors affecting the occurrence of clinically relevant bleeding events. RESULTS The analysis population comprised 5695 patients [3530 received DOACs and 2165 received vitamin K antagonists (VKAs)]. The incidence of primary outcome events (clinically relevant bleeding/100 patient-years) was 6.05 in the DOAC group and 8.42 in the VKA group, resulting in a nonsignificant 21% lower risk in the DOAC group. The DOAC group also had a nonsignificant 24%, 24%, and 34% lower risk of bleeding requiring transfusion, intracranial bleeding, and lower gastrointestinal bleeding, respectively, compared with the VKA group. A multivariate analysis of the primary outcome showed a significantly higher risk of bleeding among older patients and those with lower body weight and abnormal renal function. CONCLUSIONS In this retrospective real-world evaluation of IHD patients with NVAF and PCI, DOAC-treated patients had a lower risk of developing clinically relevant bleeding compared with the VKA group.
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Affiliation(s)
- Masato Nakamura
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan.
| | | | - Akiko Hayakawa
- Safety and Risk Management Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Takuyuki Matsumoto
- Safety and Risk Management Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Atsushi Takita
- Biostatistics and Data Management Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Chie Hasegawa
- Pharmacovigilance Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Kazuhiro Uchino
- Post Marketing Study Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Toru Sekine
- Post Marketing Study Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Tomoko Iizuka
- Post Marketing Study Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Hirokazu Tanabe
- Safety and Risk Management Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Seiji Kogure
- Safety and Risk Management Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
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11
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Tsujita K, Deguchi H, Uda A, Sugano K. Upper gastrointestinal bleeding in Japanese patients with ischemic heart disease receiving vonoprazan or a proton pump inhibitor with multiple antithrombotic agents: A nationwide database study. J Cardiol 2020; 76:51-57. [DOI: 10.1016/j.jjcc.2020.02.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 01/16/2020] [Accepted: 02/11/2020] [Indexed: 02/09/2023]
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12
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Yoshida R, Ishii H, Morishima I, Tanaka A, Morita Y, Takagi K, Yoshioka N, Hirayama K, Iwakawa N, Tashiro H, Kojima H, Mitsuda T, Hitora Y, Furusawa K, Tsuboi H, Murohara T. Impact of Nutritional and Inflammation Status on Long-Term Bleeding in Patients Undergoing Percutaneous Coronary Intervention with an Oral Anticoagulant. J Atheroscler Thromb 2019; 26:728-737. [PMID: 30584221 PMCID: PMC6711841 DOI: 10.5551/jat.47654] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
AIM Patients undergoing percutaneous coronary intervention (PCI) who require both oral anticoagulant (OAC) and antiplatelet therapy (APT) are exposed to a serious risk of bleeding. The aim of this study was to clarify the relationship among nutritional and inflammation status and long-term bleeding in patients requiring both OACs and APT after PCI. METHODS We performed PCI in 3,718 consecutive patients between April 2011 and March 2017, 302 of whom were treated with both OACs and APT. Patients were followed for up to 3 years for bleeding events, defined as the Bleeding Academic Research Consortium (BARC) class ≥3 bleeding. We retrospectively evaluated the ability of the Geriatric Nutritional Risk Index (GNRI) and high-sensitivity C-reactive protein (hs-CRP) to detect bleeding events. RESULTS During a median follow-up of 1,080 days, bleeding events were observed in 53 (17.5%) patients. Bleeding events were associated with a low GNRI (≤98) (hazard ratio [HR], 3.16; 95% confidence interval [CI], 1.84-5.45; p<0.0001) and hs-CRP level ≥2.5 mg/L (HR, 2.75; 95% CI, 1.61-4.78; p=0.0003). A low GNRI+high hs-CRP showed a 5.12-fold increase in the incidence of BARC class ≥3 bleeding (95% CI, 2.68-9.91; p<0.0001) compared with a normal GNRI+low hs-CRP. The addition of the GNRI and hs-CRP to the PRECISE-DAPT score improved C-statistics from 0.67 to 0.71 and enhanced the net reclassification improvement (NRI) and integrated discrimination improvement (IDI) (NRI, 0.36, p<0.0001; IDI, 0.066, p<0.0001). CONCLUSIONS The GNRI and hs-CRP were novel predictors of the long-term bleeding risk in patients requiring both OACs and APT after PCI.
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Affiliation(s)
- Ruka Yoshida
- Department of Cardiology, Nagoya University Hospital.,Department of Cardiology, Ogaki Municipal Hospital
| | - Hideki Ishii
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | | | | | | | | | | | - Kenshi Hirayama
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Naoki Iwakawa
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | | | - Hiroki Kojima
- Department of Cardiology, Nagoya University Hospital
| | | | - Yusuke Hitora
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | | | | | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine
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13
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Shlofmitz E, Shlofmitz R, Lee MS. The Role of Novel Oral Anticoagulants and Antiplatelet Therapy after Percutaneous Coronary Intervention: Individualizing Therapy to Optimize Outcomes. Korean Circ J 2019; 49:645-656. [PMID: 31347321 PMCID: PMC6675700 DOI: 10.4070/kcj.2019.0185] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 06/24/2019] [Indexed: 11/23/2022] Open
Abstract
The number of patients undergoing percutaneous coronary intervention (PCI) who mandate additional oral anticoagulant therapy has been increasing. Dual antiplatelet therapy (DAPT) is associated with reduced ischemic events including stent thrombosis, myocardial infarction and stroke following PCI. However, the tradeoff is an increased risk for bleeding while on DAPT. The addition of a novel oral anticoagulant (NOAC) further increases the likelihood of bleeding while on antiplatelet therapy. Thus, the overall risks and benefits for each patient undergoing PCI on NOAC must be assessed and therapy individualized to ensure optimal therapy for each unique situation. Patients on NOAC undergoing PCI should undergo routine assessment with intravascular imaging as the role of high-risk lesion-related features have increased importance prior to determining optimal duration of treatment with DAPT. We review the best practices for the pharmacologic management of patients requiring anticoagulation with NOAC who are treated with PCI and require antiplatelet therapy.
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Affiliation(s)
- Evan Shlofmitz
- MedStar Washington Hospital Center, Washington, D.C., USA
| | | | - Michael S Lee
- Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA.
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14
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Impact of Postdischarge Bleeding on Long-Term Mortality in Percutaneous Coronary Intervention Patients Taking Oral Anticoagulants. J Cardiovasc Pharmacol 2019; 74:210-217. [PMID: 31306368 DOI: 10.1097/fjc.0000000000000702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although postdischarge bleeding (PDB) is known to negatively affect long-term outcome in patients undergoing percutaneous coronary intervention (PCI) with antiplatelet therapy (APT), the prognostic importance of PDB in patients who require both oral anticoagulants (OACs) and APT has not been fully elucidated. Among 3718 consecutive patients who underwent PCI, 302 patients were treated with both OACs and APT. We evaluated the association between PDB and 3-year all-cause mortality, as estimated by a time-updated Cox proportional hazard regression model. We performed nearest-neighbor matching on the propensity score to adjust the differences in baseline characteristics. Among 302 patients treated with OACs and APT, PDB was observed in 98 patients at a median time of 239 days. Patients experienced PDB had significantly higher incidence of 3-year all-cause mortality in the overall cohort and 94 propensity-score-matched pairs (hazard ratio 6.21, 95% confidence interval 3.29-11.72, P < 0.0001; and hazard ratio 6.13, 95% confidence interval 2.68-14.02, P < 0.0001, respectively). The risk of subsequent mortality was the highest within 180 days after PDB (58.3% within 180 days and 75.0% within 1 year). In conclusion, PDB was significantly associated with long-term mortality in patients taking both OACs and APT after PCI.
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15
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Triple, dual, and single antithrombotic therapy for patients with atrial fibrillation undergoing percutaneous coronary intervention. Cardiovasc Interv Ther 2019; 35:44-51. [PMID: 31281936 DOI: 10.1007/s12928-019-00600-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 06/21/2019] [Indexed: 12/21/2022]
Abstract
In patients with atrial fibrillation (AF), concomitant coronary artery disease is often present, and vice versa. Although both AF and coronary artery disease need antithrombotic therapy to reduce ischemic events, optimal antithrombotic regimens for patients with AF undergoing percutaneous coronary intervention (PCI) remain unclear. Triple therapy, a combination of oral anticoagulant plus dual antiplatelet therapy with aspirin and P2Y12 inhibitor, has been used for patients with AF undergoing PCI as an initial antithrombotic strategy in the recent decade. However, triple therapy is well-known to induce severe bleeding events. Recently, several clinical trials have been published and guideline recommendations have been updated. This review article summarizes current evidence concerning antithrombotic therapy in patients with AF undergoing PCI.
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16
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Fukaya H, Ako J. Bleeding risk score in Japanese patients on antiplatelets plus an anticoagulant. J Cardiol 2019; 73:466-467. [DOI: 10.1016/j.jjcc.2018.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 11/17/2018] [Indexed: 10/27/2022]
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