HAS-BLED score predicts risk of in-hospital major bleeding in patients with acute non-ST segment elevation myocardial infarction

Performance of the Academic Research Consortium High Bleeding Risk Criteria in Patients With ST-Segment Elevation Myocardial Infarction: A Single Center Study

We assessed the ability of predicting mortality and total in-hospital bleeding and adverse outcomes by the Academic Research Consortium High Bleeding Risk (ARC-HBR) criteria in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (pPCI). A total of 1441 STEMI patients were recruited: HBR group 354 (25%) patients and non-HBR group of 1087 (75%) patients. A total of 131 patients (9%) had a bleeding complication during hospitalization. The bleeding complications were also categorized according to other conventional bleeding scores. According to these conventional scores, all bleeding categories were associated with HBR. In univariate logistic regression analysis, female gender, diabetes mellitus, hypertension (HT) and HBR were associated with in-hospital bleeding. However, in multivariable analysis only HT (Odds Ratio [OR] 1.528, 95% CI 1.020-2.290; P = .040) and HBR (OR 1.612, 95% CI 1.075-2.428; P = .022) independently predicted total in-hospital bleeding complications. Hospital duration was longer and mortality rate was significantly higher in patients with HBR (OR 8.755, 95% CI 5.864-13.074; P < .01). The ARC-HBR criteria may predict in-hospital bleeding events and adverse outcomes in STEMI patients undergoing pPCI.

The prognostic value of ORBIT risk score in predicting major bleeding in patients with acute coronary syndrome

BACKGROUND

The most significant adverse effect of antithrombotic medication in acute coronary syndrome (ACS) is major bleeding, which is related to increased mortality. Studies on ORBIT risk score in predicting major bleeding in ACS patients are limited.

OBJECTIVE

This research aimed to examine whether the ORBIT score calculated at the bedside can identify major bleeding risk in patients with ACS.

METHODS

This research was retrospective, observational, and conducted at a single center. Analyses of receiver operating characteristics (ROC) were utilized to define the diagnostic value of CRUSADE and ORBIT scores. The predictive performances of the two scores were compared using DeLong's method. Discrimination and reclassification performances were evaluated by the integrated discrimination improvement (IDI), and net reclassification improvement (NRI).

RESULTS

The study included 771 patients with ACS. The mean age was 68.7 ± 8.6 years, with 35.3 % females. 31 patients had major bleeding. Twenty-three of these patients were BARC 3 A, five were BARC 3 B, and three were BARC 3 C. Bleeding history [OR (95 % CI), 2.46 (1.02-5.94), p = 0.021], hemoglobin levels [OR (95 % CI), 0.54 (0.45-0.63), p < 0.001], and age > 74 years [OR (95 % CI), 1.03 (1.01-1.06), p = 0.039] were independent predictors of major bleeding. The ORBIT score was an independent predictor of major bleeding in the multivariate analysis: continuous variables [OR (95 % CI), 2.53 (2.61-3.95), p < 0.001] and risk categories [OR (95 % CI), 3.06 (1.69-5.52), p < 0.001]. Comparison of c-indexes for major bleeding events revealed a non-significant difference for the discriminative ability of the two tested scores (p = 0.07) with a continuous NRI of 6.6 % (p = 0.026) and an IDI of 4.2 % (p < 0.001).

CONCLUSION

In ACS patients, the ORBIT score independently predicted major bleeding.

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.

Meta-Analysis of Bleeding Scores Performance for Acute Coronary Syndrome

BACKGROUND

Bleeding is a common and frequently devastating complication in acute coronary syndrome (ACS). It is critical to evaluate in the current era of ACS management involving invasive strategies and potent anti-thrombotics. Risk models remain under-utilised in this setting but may guide the choice and duration of therapy. We compared their performances for predicting bleeding in ACS patients in this meta-analysis.

METHODS

Medline, EMBASE, Cochrane and Scopus were searched for relevant articles from 1980 to 31 December 2017 assessing external validation of risk scores for bleeding after ACS. Two (2) authors independently reviewed the searched studies for eligibility, followed by pooled analyses using random effects models.

RESULTS

Amongst 1,843 articles searched, 73 full-texts were reviewed and 17 studies totalling 18,155 patients were included for analysis. C-statistics (95% confidence interval) for predicting in-hospital major bleeding by risk model were Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE) 0.714 (0.659-0.779), Acute Catheterization and Urgent Intervention Triage strategY (ACUITY) 0.711 (0.626-0.797), Acute Coronary Treatment and Intervention Outcomes Network (ACTION) 0.767 (0.737-0.797), Global Registry of Acute Coronary Events (GRACE) 0.689 (0.473-0.905) and HAS-BLED 0.636 (0.460-0.812). CRUSADE also predicted bleeding during medium-term follow-up c=0.704 (0.644-0.765). It performed better for radial versus femoral access (c=0.826 and 0.734), invasive versus non-invasive strategy (c=0.752 and 0.625) and similarly for ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI) (c=0.791 and 0.760). Heterogeneities of studies and paucity of studies assessing risk scores beyond CRUSADE were important limitations.

CONCLUSIONS

Acute coronary syndrome-specific bleeding scores had moderate discrimination for bleeding, while the GRACE and HAS-BLED scores could not. The ACTION score had the highest pooled c-statistic, while the CRUSADE score was the most widely studied, and also performed better for invasive strategy and radial access subgroups.

Antiplatelet therapy after PCI in patients with high risk of bleeding

The progress of percutaneous coronary interventions (PCI) over the last few decades facilitated treatment of increasingly complex patient populations. The introduction of drug-eluting stents (DESs) led to need of stronger and prolonged inhibition of platelets which in turn increased the incidence of bleeding complications. The identification and management of patients at high bleeding risk (HBR) during and after percutaneous coronary interventions (PCI) is still problematic in everyday clinical practice.

Performance of bleeding risk scores in dialysis patients

BACKGROUND

Bleeding risk scores have been created to identify patients with an increased bleeding risk, which could also be useful in dialysis patients. However, the predictive performances of these bleeding risk scores in dialysis patients are unknown. Therefore, the aim of this study was to validate existing bleeding risk scores in dialysis patients.

METHODS

A cohort of 1745 incident dialysis patients was prospectively followed for 3 years during which bleeding events were registered. We evaluated the discriminative performance of the Hypertension, Abnormal kidney and liver function, Stroke, Bleeding, Labile INR, Elderly and Drugs or alcohol (HASBLED), the AnTicoagulation and Risk factors In Atrial fibrillation (ATRIA), the Hepatic or kidney disease, Ethanol abuse, Malignancy, Older age, Reduced platelet count or Reduced platelet function, Hypertension, Anaemia, Genetic factors, Excessive fall risk and Stroke (HEMORR2HAGES) and the Outcomes Registry for Better Informed Treatment (ORBIT) bleeding risk scores by calculating C-statistics with 95% confidence intervals (CI). In addition, calibration was evaluated by comparing predicted and observed risks.

RESULTS

Of the 1745 dialysis patients, 183 patients had a bleeding event, corresponding to an incidence rate of 5.23/100 person-years. The HASBLED [C-statistic of 0.58 (95% CI 0.54-0.62)], ATRIA [C-statistic of 0.55 (95% CI 0.51-0.60)], HEMORR2HAGES [C-statistic of 0.56 (95% CI 0.52-0.61)] and ORBIT [C-statistic of 0.56 (95% CI 0.52-0.61)] risk scores had poor discriminative performances in dialysis patients. Furthermore, the calibration analyses showed that patients with a low risk of bleeding according to the HASBLED, ATRIA, HEMORR2HAGES and ORBIT bleeding risk scores had higher incidence rates for bleeding in our cohort than predicted.

CONCLUSIONS

The HASBLED, ATRIA, HEMORR2HAGES and ORBIT bleeding risk scores had poor predictive abilities in dialysis patients. Therefore, these bleeding risk scores may not be useful in this population.

Evaluation of Bleeding Risk in Patients with Acute Myocardial Infarction Undergoing Transradial Percutaneous Coronary Intervention

We investigated the accuracy of various bleeding risk scores to estimate the bleeding risk in patients with acute myocardial infarction (AMI) managed with percutaneous coronary intervention (PCI) access via the radial artery.We retrospectively enrolled 1,651 patients who were definitively diagnosed with ST-elevation myocardial infarction (STEMI) or non-STEMI (NSTEMI). We assessed the predictive validities of 30-day bleeding events in various scoring systems using receiver operating characteristic curves.Overall, ACUITY-HORIZONS exhibited the highest area under the curve to predict 30-day bleeding, followed by ACTION and CRUSADE; HAS-BLED displayed the lowest score. With a cut-off of 17, ACUITY-HORIZONS demonstrated the best discrimination for the Thrombolysis in Myocardial Infarction (TIMI) 30-day serious bleeding rate. We observed significant differences among all-cause death, cardiovascular death, and major adverse cardiac events between the ACUITY-HORIZONS groups with a score of ≤ 17 and > 17. ACUITY-HORIZONS score > 17, initial systolic blood pressure (SBP) < 90 mmHg, and Killip III and IV upon admission positively predicted the 30-day bleeding risk, whereas myocardial infarction (MI) and TIMI major bleeding within 30 days, heart failure at admission, and initial SBP < 90 mmHg positively predicted the 30-day mortality.Comparatively, ACUITY-HORIZON is the most reliable system in predicting 30-day bleeding for patients with AMI via transradial PCI. In the transradial scenario, bleeding and MI within 30 days are substantially related to 30-day mortality.

Utility of the HAS-BLED score for risk stratification of patients with acute coronary syndrome

HAS-BLED score was developed for bleeding prediction in patients with atrial fibrillation (AF). Recently, it was also used in patients undergoing percutaneous coronary interventions (PCI). This study analyzes the HAS-BLED predictivity for bleedings and mortality in patients with acute coronary syndromes (ACS) without AF, and evaluates the utilization of alternative criteria for renal dysfunction. The study population was composed of 704 patients with ACS. Six-hundred and eleven patients completed the follow-up. The HAS-BLED score was calculated both using the original definition of renal dysfunction, both using three alternative eGFR thresholds (< 30, < 60 and ≤ 90 ml/min/1.73 mq). In-hospital and post-discharge bleedings and mortality were recorded, and calibration and discrimination of the various risk models were evaluated using the Hosmer-Lemeshow test and the C-statistic. In-hospital bleedings were 4.7% and mortality was 2.7%. Post-discharge bleedings were 3.1% and mortality was 4.4%. Regarding bleeding events and in-hospital mortality, the HAS-BLED original risk model demonstrated a moderate-to-good discriminative performance (C-statistics from 0.65 to 0.76). No significant differences were found in predictive accuracy when applying alternative definitions of renal dysfunction based on eGFR, with the exception of post-discharge mortality, for which HAS-BLED model assuming an eGFR value < 60 ml/min/1.73 mq showed a discriminative performance significantly higher in comparison to the other risk models (C-statistic 0.71 versus 0.64-0.66). In conclusion, in our ACS population, the HAS-BLED risk score showed a fairly good predictive accuracy regarding in-hospital and follow-up bleeding events and in-hospital mortality. The use of renal dysfunction alternative criteria based on eGFR values resulted in out-of hospital mortality predictive accuracy enhancement.

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

BACKGROUND

Predictive 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.

METHODS

A 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.

RESULTS

The 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.

CONCLUSIONS

HAS-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.