Predicting anticoagulant-related bleeding in patients with venous thromboembolism: a clinically oriented review

Klok, Frederikus A.; Kooiman, Judith; Huisman, Menno V.; Konstantinides, Stavros; Lankeit, Mareike

doi:10.1183/09031936.00040714

Cited by 96 publications

(85 citation statements)

References 80 publications

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“…The predictive value of the scores for ''later occurring bleeding'' seemed better than for ''early bleeding'', especially for the HAS-BLED score. Although both the risk of bleeding is highest in the first days of treatment due to overlapping heparin and VKA treatment as well as the manifestation of occult bleeding foci, predicting bleeding after the 'vulnerable period' and is clinically most relevant [5]. Could the surprising limited predictive value of the scores in our study be caused by our study design or patient selection?…”

Section: Discussionmentioning

confidence: 71%

“…In patients included in PERGO after 2011, all scores were calculated prospectively; in patients included before 2011, scores were Table 1 [5]. For calculation of the HAS-BLED, all patients were scored with 0 points for ''labile INR'' since therapeutic anticoagulation with VKA was not initiated yet at baseline [9].…”

Section: Bleeding Prediction Scoresmentioning

confidence: 99%

“…The most feared complication of any anticoagulant therapy is major bleeding, which occurs with a rate of 7.22 per 100 patient-years and has a case-fatality rate of 13-20 %, with the highest risk of bleeding in the first 7 days of treatment [3][4][5]. Hence, accurate and standardized identification of PE patients at increased risk of major haemorrhages helps the clinician in defining the most optimal treatment regime and duration.…”

Section: Introductionmentioning

confidence: 99%

“…Some bleeding risk-prediction scores for patients with venous thromboembolism (VTE) have been proposed, e.g. the Kuijer and RIETE scores [5][6][7]. However, these scores are limited by retrospective study design and lack external validation.…”

Section: Introductionmentioning

confidence: 99%

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

Klok

Niemann

Dellas

et al. 2015

J Thromb Thrombolysis

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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.

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Section: Discussionmentioning

confidence: 71%

Section: Bleeding Prediction Scoresmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

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

Klok

Niemann

Dellas

et al. 2015

J Thromb Thrombolysis

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“…However, it remains challenging to quantify the individual risk of major bleeding and although risk assessment models have been developed in the past years, they still, without exception, lack sufficient validation in cohort and management studies (Klok et al , 2015). …”

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confidence: 99%

Predictive value of venous thromboembolism (VTE)‐BLEED to predict major bleeding and other adverse events in a practice‐based cohort of patients with VTE: results of the XALIA study

et al. 2018

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SummaryVenous thromboembolism (VTE)‐BLEED, a decision tool for predicting major bleeding during chronic anticoagulation for VTE has not yet been validated in practice‐based conditions. We calculated the prognostic indices of VTE‐BLEED for major bleeding after day 30 and day 90, as well as for recurrent VTE and all‐cause mortality, in 4457 patients enrolled in the international, prospective XALIA study. The median at‐risk time was 190 days (interquartile range 106–360). The crude hazard ratio (HR) for major bleeding after day 30 was 2·6 [95% confidence interval (CI) 1·3–5·2] and the treatment‐adjusted HR was 2·3 (95% CI 1·1–4·5) for VTE‐BLEED high (versus low) risk patients: the corresponding values for major bleeding after day 90 were 3·8 (95% CI 1·6–9·3) and 3·2 (95% CI 1·3–7·7), respectively. The predictive value of VTE‐BLEED was similar in selected patients with unprovoked VTE or those treated with rivaroxaban. High VTE‐BLEED score was associated with higher incidence of all‐cause mortality (treatment‐adjusted HR 11, 95% CI 4·8–23), but not evidently with recurrent VTE (treatment‐adjusted HR 1·5; 95% CI 0·85–2·7). These results confirm the predictive value of VTE‐BLEED in practice‐based data in patients treated with rivaroxaban or conventional anticoagulation, supporting the hypothesis that VTE‐BLEED may be useful for making management decisions on the duration of anticoagulant therapy.

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

Klok

Presles

Tromeur

et al. 2019

Research and Practice in Thrombosis and Haemostasis

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Introduction VTE‐BLEED is a validated score for identification of patients at increased risk of major bleeding during extended anticoagulation for venous thromboembolism (VTE). It is unknown whether VTE‐BLEED high‐risk patients also have an increased risk for recurrent VTE, which would limit the potential usefulness of the score. Methods This was a post hoc analysis of the randomized, double‐blind, placebo‐controlled PADIS‐PE trial that randomized patients with a first unprovoked pulmonary embolism (PE) initially treated during 6 months to receive an additional 18‐month of warfarin vs. placebo. The primary outcome of this analysis was recurrent VTE during 2‐year follow‐up after anticoagulant discontinuation, that is, after the initial 6‐month treatment in the placebo arm and after 24 months of anticoagulation in the active treatment arm. This rate, adjusted for study treatment allocation, was compared between patients in the high‐ vs. low‐risk VTE‐BLEED group. Results In complete case analysis (n = 308; 82.4% of total population), 89 (28.9%) patients were classified as high risk; 44 VTE events occurred after anticoagulant discontinuation during 668 patient‐years. The cumulative incidence of recurrent VTE was 16.4% (95% confidence interval [CI], 10.0%‐26.1%; 14 events) and 14.6% (95% CI, 10.4%‐20.3%; 30 events) in the high‐risk and low‐risk VTE‐BLEED groups, respectively, for an adjusted hazard ratio of 1.16 (95% CI, 0.62‐2.19). Conclusion In this study, patients with unprovoked PE classified at high risk of major bleeding by VTE‐BLEED did not have a higher incidence of recurrent VTE after cessation of anticoagulant therapy, supporting the potential yield of the score for making management decisions on the optimal duration of anticoagulant therapy.

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Predicting anticoagulant-related bleeding in patients with venous thromboembolism: a clinically oriented review

Cited by 96 publications

References 80 publications

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

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

Predictive value of venous thromboembolism (VTE)‐BLEED to predict major bleeding and other adverse events in a practice‐based cohort of patients with VTE: results of the XALIA study

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

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