Performance of five different bleeding-prediction scores in patients with acute pulmonary embolism

Abstract

Bleeding-prediction scores may help guiding management of patients with pulmonary embolism (PE), although no such score has been validated. We aimed to externally validate and compare two bleeding-prediction scores for venous thromboembolism to three scores developed for patients with atrial fibrillation in a real-world cohort of PE patients. We performed a prospective observational cohort study in 448 consecutive PE patients who were treated with heparins followed by vitamin-K-antagonists. The Kuijer, RIETE, HEMORR2HAGES, HAS-BLED and ATRIA scores were assessed at baseline. All patients were followed for the occurrence of major bleeding over a 30-day period. The accuracies of both the overall, original 3-level and newly defined optimal 2-level outcome of the scores were evaluated and compared, both for the 30-day period as well as for bleeding occurring in versus after the first week of treatment. 20 of 448 patients suffered major bleeding resulting in a cumulative incidence of 4.5 % (95 % CI 2.5-6.5). The predictive power of all five scores for bleeding was poor (c-statistics 0.57-0.64), both for the 3-level and 2-level score outcomes. No individual score was found to be superior. The HAS-BLED score had a good c-statistic for bleedings occurring after the first week of treatment (0.75, 95 % CI 0.47-1.0). Current available scoring systems have insufficient accuracy to predict overall anticoagulation-associated bleeding in patients treated for acute PE. To optimally target bleeding-prevention strategies, the development of a high quality PE-specific risk score is urgently needed.

Evaluation of the predictive value of the bleeding prediction score VTE‐BLEED for recurrent venous thromboembolism

“…To ensure usefulness in clinical practice, prediction scores aiming at determining the optimal duration of anticoagulant therapy for VTE should demonstrate consistency and straightforwardness in their application. In the case of the present clinical question, this may be complicated by the time‐varying nature of numerous bleeding risk predictors included in scores such as the HAS‐BLED and the American College of Chest Physicians score . In contrast, the VTE‐BLEED includes only 1 potentially inconstant variable, namely, “male with uncontrolled arterial hypertension,” while all other variables are clearly defined and largely objective and tend to be fairly constant over time in most patients.…”

“…This suggests more consistent and thereby likely reliable estimates of bleeding risks and broader functionality of the VTE‐BLEED than other available scores. Furthermore, in contrast with other currently available bleeding risk scores, the VTE‐BLEED was evaluated and validated both in nonselected VTE patients and in patients with unprovoked VTE, as well as for all currently available classes of oral anticoagulants . Additionally, the binary categorization used in the VTE‐BLEED limits the commonly encountered ambiguity surrounding clinical management of patients classified at “intermediate risk” according to other bleeding prediction scores.…”

The predictive value of plasma osmolality for in‐hospital mortality in patients with acute pulmonary embolism

“…Cardiogenic shock was defined as systolic pressure of <90 mm Hg or systolic pressure drop greater than or equal to 40 mm Hg for >15 minutes without new‐onset arrhythmia, hypovolemia or sepsis . Major bleeding was described in accordance of the definition proposed by the Control of Anticoagulation Subcommittee of the International Society on Thrombosis and Hemostasis; I‐ fatal bleeding and/or II‐ symptomatic bleeding in a critical area or organ, such as intracranial, intraspinal, intraocular, retroperitoneal, intra‐articular, pericardial or intramuscular with compartment syndrome, and/or III‐bleeding causing a drop of haemoglobin level of 20 g/L or more or leading to transfusion of two or more units of red blood cells …”

British Thoracic Society Guideline for the initial outpatient management of pulmonary embolism (PE)

“…Klok et al 42 externally validated and compared the predictive value of the HEMORR2HAGES, HASBLED and ATRIA scores to the Kuijer and RIETE scores for the occurrence of major bleeding complications over a 30-day period in 448 consecutive patients with PE treated with a VKA. Most bleeding events (16/20) occurred in the first seven days after treatment initiation, with four bleeding complications between days 8 and 30.…”