Sunday, 26 August 2012

Background: Hemorrhagic complications are strongly linked with subsequent adverse outcomes in acute coronary syndrome (ACS) patients. Various risk scores \n(RS) are available to estimate the bleeding risk in these patients. \nAims: To compare the predictive accuracy of the three contemporary bleeding \nRS in ACS. \nMethods: We studied 4500 consecutive patients with ACS. For each patient, \nthe ACTION, CRUSADE, and Mehran et al bleeding RS were calculated. We \nassessed their performance either for the prediction of their own major bleeding events or to predict the TIMI serious (major and minor) bleeding episodes \nin the overall population, in patients with non-ST elevation ACS (NSTEACS) \nand in those with ST-elevation myocardial infarction (STEMI) patients. Calibration \n(Hosmer-Lemeshow test) and discrimination (c-statistic) for the three RS were \ncomputed and compared. We used the concept of net reclassification improvement (NRI) to compare the incremental prognostic value of using a particular RS \nover the remaining scores in predicting the TIMI serious bleeding. \nResults: The best predictive accuracy was obtained by the CRUSADE score either for the prediction of its own major bleeding events (c-statistic=0.80, 0.791, \nand 0.81 for the entire sample, for STEMI, and for NSTEACS patients, respectively) or to predict the TIMI serious bleed occurrence (c-statistic=0.741, 0.738,and 0.745 for the whole population, for STEMI and NSTEACS patients, respectively). The lowest bleeding rates observed in patients classified as low risk corresponded to the CRUSADE RS. All scores performed modestly in patients who \ndid not undergo coronariography (all c-statistic <0.70). The CRUSADE score was \nsignificantly superior to the ACTION model in predicting the TIMI serious bleeding \noccurrence in terms of NRI overall and by ACS subgroups (p<0.05). Overall, the \nCRUSADE RS exhibited better calibration for predicting the TIMI serious bleeding \ncompared to the ACTION and Mehran et al scores (Hosmer-Lemeshow p-values \nof 0.26, 0.13, and 0.07, respectively). \nConclusion: The CRUSADE score represents, among the more contemporary \nbleeding RS, the most accurate and reliable quantitative clinical tool in STEACS \nand STEMI patients. We encourage the utilization of the CRUSADE index for \nbleeding risk stratification purposes in daily clinical practice and in ACS outcome \nstudies. The performance of the three more contemporary bleeding RS is modest \nin those patients who received conservative management.