Comparison of different bleeding risk scores to predict in-hospital major bleeding in acute pulmonary embolism patients who have undergone thrombolytic treatment

Abstract Background Hemorrhagic complications are a major obstacle for aggressive antithrombotic therapy in patients with acute pulmonary embolism (PE). Objectives We aimed to develop a simple risk score for predicting major bleeding (MB) in patients with acute PE using medical history and laboratory data at admission, including the potential influence of thrombolytic therapy, and to compare its predictive power to bleeding risk scores previously developed for patients with atrial fibrillation or venous thromboembolism. Methods A total of 630 consecutive patients treated for PE in six Serbian University hospitals were followed up for the occurrence of MB over a 90-day period after admission. A 6-component bleeding risk score was developed after Cox regression analysis of possible variables presented at admission. The use of thrombolytic therapy was also tested as a risk factor for bleeding and was integrated into the score. The ATRIA, HAS BLED, RIETE and VTE-BLEED scores were calculated for each patient at baseline and the predictive performances were compared with new score using c-statistics. Results MB occurred in 61 (9.7%) patients during the 90-day follow-up, with no increased risk of all-cause mortality (p=0.108). Six independent factors associated with MB were included in the final model (previous bleeding, leukocyte count ≥14x109/L, receipt of thrombolytic therapy, anemia, drugs associated with bleeding, and recent surgery; BLLADS). For the six- and five-variable models (without points for thrombolysis), C-indices were 0.774 (95% confidence interval [CI], 0.713–0.835, p<0.001) and 0.713 (95% CI, 0.639–0.788, p<0.001), respectively. The predictive power of the BLLADS score was found to be superior in comparison with other four scores: c-index 0.779 (95% CI 0.716–0.841, p<0.001), 0,614 (95% CI 0.535–0.692, p=0.005), 0.591 (95% CI 0.518–0.664, p=0.025), 0.589 (95% CI 0.518–0.659, p=0.029), 0.586 (95% CI 0.508–0.664, p=0.035), for continuous BLLADS, RIETE, VTE-BLEED, ATRIA and HAS BLED scores, respectively. Conclusion A simple six-variable score including the use of thrombolysis was developed with sufficient discriminative capacity comparing to current available scores for the prediction of 90-day MB for non-selected PE patients.

Download Full-text

ACCURACY OF AVAILABLE SCORING SYSTEMS FOR IN-HOSPITAL MAJOR BLEEDING PREDICTION IN ACUTE PULMONARY EMBOLISM PATIENTS

Journal of the American College of Cardiology ◽

10.1016/s0735-1097(21)03183-1 ◽

2021 ◽

Vol 77 (18) ◽

pp. 1827

Author(s):

Romain Chopard ◽

Camille Mathonier ◽

Fiona Ecarnot ◽

Matthieu Besutti ◽

Nicolas Falvo ◽

...

Keyword(s):

Pulmonary Embolism ◽

Major Bleeding ◽

Acute Pulmonary Embolism ◽

Scoring Systems

Download Full-text

Risk Stratification in Acute Pulmonary Embolism: The Latest Algorithms

Seminars in Respiratory and Critical Care Medicine ◽

10.1055/s-0041-1722898 ◽

2021 ◽

Vol 42 (02) ◽

pp. 183-198

Author(s):

Georgios A. Triantafyllou ◽

Oisin O'Corragain ◽

Belinda Rivera-Lebron ◽

Parth Rali

Keyword(s):

Pulmonary Embolism ◽

Risk Stratification ◽

Prediction Models ◽

Bleeding Risk ◽

Hemodynamic Instability ◽

Reperfusion Therapy ◽

Mortality Prediction ◽

Risk Scores ◽

Short Term Mortality ◽

Urgent Patient

AbstractPulmonary embolism (PE) is a common clinical entity, which most clinicians will encounter. Appropriate risk stratification of patients is key to identify those who may benefit from reperfusion therapy. The first step in risk assessment should be the identification of hemodynamic instability and, if present, urgent patient consideration for systemic thrombolytics. In the absence of shock, there is a plethora of imaging studies, biochemical markers, and clinical scores that can be used to further assess the patients' short-term mortality risk. Integrated prediction models incorporate more information toward an individualized and precise mortality prediction. Additionally, bleeding risk scores should be utilized prior to initiation of anticoagulation and/or reperfusion therapy administration. Here, we review the latest algorithms for a comprehensive risk stratification of the patient with acute PE.

Download Full-text

Accuracy of available scoring systems for prediction of in-hospital major bleeding in acute pulmonary embolism patients

Archives of Cardiovascular Diseases Supplements ◽

10.1016/j.acvdsp.2020.10.176 ◽

2021 ◽

Vol 13 (1) ◽

pp. 78

Author(s):

C. Mathonier ◽

R. Chopard ◽

F. Ecarnot ◽

N. Falvo ◽

E. Kalbacher ◽

...

Keyword(s):

Pulmonary Embolism ◽

Major Bleeding ◽

Acute Pulmonary Embolism ◽

Scoring Systems

Download Full-text

Thrombolytic Treatment of Acute Pulmonary Embolism: Toward the End of a Long-Lasting Debate?

Venous Thromboembolism ◽

10.1007/4-431-27121-x_2 ◽

2006 ◽

pp. 13-22

Author(s):

Stavros Konstantinides

Keyword(s):

Pulmonary Embolism ◽

Acute Pulmonary Embolism ◽

Thrombolytic Treatment

Download Full-text

CURRENT VIEW ON ANTICOAGULANT AND THROMBOLYTIC TREATMENT OF ACUTE PULMONARY EMBOLISM

The Russian Archives of Internal Medicine ◽

10.20514/2226-6704-2019-9-5-348-366 ◽

2019 ◽

Vol 9 (5) ◽

pp. 348-366

Author(s):

G. G. Taradin ◽

G. A. Ignatenko ◽

N. T. Vatutin ◽

I. V. Kanisheva

Keyword(s):

Pulmonary Embolism ◽

Venous Thromboembolism ◽

Acute Pulmonary Embolism ◽

Oral Anticoagulants ◽

Medical Intervention ◽

Bleeding Complications ◽

Current View ◽

Anticoagulant Treatment ◽

Thrombolytic Treatment ◽

Systemic Thrombolysis

The presented review concerns contemporary views on specific aspects of anticoagulant and thrombolytic treatment of venous thromboembolism and mostly of acute pulmonary embolism. Modern classifications of patients with acute pulmonary embolism, based on early mortality risk and severity of thromboembolic event, are reproduced. The importance of multidisciplinary approach to the management of patients with pulmonary embolism with the assistance of cardiologist, intensive care specialist, pulmonologist, thoracic and cardiovascular surgeon, aimed at the management of pulmonary embolism at all stages: from clinical suspicion to the selection and performing of any medical intervention, is emphasized. Anticoagulant treatment with the demonstration of results of major trials, devoted to efficacy and safety evaluation of anticoagulants, is highlighted in details. Moreover, characteristics, basic dosage and dosage scheme of direct (new) oral anticoagulants, including apixaban, rivaroxaban, dabigatran, edoxaban and betrixaban are described in the article. In particular, the management of patients with bleeding complications of anticoagulant treatment and its application in cancer patients, who often have venous thromboembolism, is described. Additionally, modern approaches to systemic thrombolysis with intravenous streptokinase, urokinase and tissue plasminogen activators are presented in this review. The indications, contraindications, results of clinical trials devoted to various regimens of thrombolytic therapy, including treatment of pulmonary embolism by lower doses of fibrinolytic agents, are described.

Download Full-text

Pulmonary embolism in acute medicine: a case-based review incorporating latest guidelines in the COVID-19 era

British Journal of Hospital Medicine ◽

10.12968/hmed.2020.0300 ◽

2020 ◽

Vol 81 (6) ◽

pp. 1-12 ◽

Cited By ~ 1

Author(s):

Alexander Stevenson ◽

Sarah Davis ◽

Nick Murch

Keyword(s):

Pulmonary Embolism ◽

Risk Stratification ◽

Acute Pulmonary Embolism ◽

Severe Disease ◽

Treatment Options ◽

Risk Scores ◽

Pulmonary Vasculature ◽

Catheter Directed Thrombolysis ◽

Imaging Results ◽

Venous Thromboembolic Events

Pulmonary embolism remains an important cause of morbidity and mortality in the UK, particularly following the outbreak of the novel coronavirus 2019 (COVID-19), where those infected have an increased prevalence of venous thromboembolic events. The pathophysiology in COVID-19 patients is thought to relate to a thromboinflammatory state within the pulmonary vasculature, triggered by the infection, but other risk factors such as reduced mobility, prolonged immobilisation and dehydration are likely to contribute. Several societies have released comprehensive guidelines emphasising the importance of risk stratification in patients with acute pulmonary embolism. They advocate the use of clinically validated risk scores in conjunction with biochemical and imaging results. Patients with mild disease can now be managed in the outpatient setting and with newly developed therapies, such as catheter-directed thrombolysis, becoming available in more centres, treatment options for those with more severe disease are also expanding. This article presents four theoretical but realistic cases, each diagnosed with acute pulmonary embolism, but differing in levels of severity. These demonstrate how the guidelines can be applied in a clinical setting, with particular focus on risk stratification and management.

Download Full-text

GARFIELD-AF model for prediction of stroke and major bleeding in atrial fibrillation: a Danish nationwide validation study

BMJ Open ◽

10.1136/bmjopen-2019-033283 ◽

2019 ◽

Vol 9 (11) ◽

pp. e033283 ◽

Cited By ~ 3

Author(s):

Frederik Dalgaard ◽

Karen Pieper ◽

Freek Verheugt ◽

A John Camm ◽

Keith AA Fox ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischaemic Stroke ◽

Major Bleeding ◽

Risk Model ◽

Oral Anticoagulants ◽

External Validation ◽

Bleeding Risk ◽

Risk Scores ◽

Secondary Outcome

ObjectivesTo externally validate the accuracy of the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) model against existing risk scores for stroke and major bleeding risk in patients with non-valvular AF in a population-based cohort.DesignRetrospective cohort study.SettingDanish nationwide registries.Participants90 693 patients with newly diagnosed non-valvular AF were included between 2010 and 2016, with follow-up censored at 1 year.Primary and secondary outcome measuresExternal validation was performed using discrimination and calibration plots. C-statistics were compared with CHA2DS2VASc score for ischaemic stroke/systemic embolism (SE) and HAS-BLED score for major bleeding/haemorrhagic stroke outcomes.ResultsOf the 90 693 included, 51 180 patients received oral anticoagulants (OAC). Overall median age (Q1, Q3) were 75 (66–83) years and 48 486 (53.5%) were male. At 1-year follow-up, a total of 2094 (2.3%) strokes/SE, 2642 (2.9%) major bleedings and 10 915 (12.0%) deaths occurred. The GARFIELD-AF model was well calibrated with the predicted risk for stroke/SE and major bleeding. The discriminatory value of GARFIELD-AF risk model was superior to CHA2DS2VASc for predicting stroke in the overall cohort (C-index: 0.71, 95% CI: 0.70 to 0.72 vs C-index: 0.67, 95% CI: 0.66 to 0.68, p<0.001) as well as in low-risk patients (C-index: 0.64, 95% CI: 0.59 to 0.69 vs C-index: 0.57, 95% CI: 0.53 to 0.61, p=0.007). The GARFIELD-AF model was comparable to HAS-BLED in predicting the risk of major bleeding in patients on OAC therapy (C-index: 0.64, 95% CI: 0.63 to 0.66 vs C-index: 0.64, 95% CI: 0.63 to 0.65, p=0.60).ConclusionIn a nationwide Danish cohort with non-valvular AF, the GARFIELD-AF model adequately predicted the risk of ischaemic stroke/SE and major bleeding. Our external validation confirms that the GARFIELD-AF model was superior to CHA2DS2VASc in predicting stroke/SE and comparable with HAS-BLED for predicting major bleeding.

Download Full-text