Bayer Pharma AG

Essence of this Article

The benefits of adding an anticoagulant to antiplatelet therapy in the secondary prevention of acute coronary syndrome (ACS) must be balanced against the associated increased risk of bleeding. Risk stratification schemes that can identify patients at increased risk of bleeding events are, therefore, useful in clinical decision making. Several risk stratification schemes for the evaluation of short-term bleeding risks in patients with ACS have been developed, including the CRUSADE score which predicts the risk of in-hospital major bleeding.

Risk factors for bleeding

The benefits of adding an anticoagulant to antiplatelet therapy in the secondary prevention of ACS must be balanced against the associated increased risk of bleeding. Risk stratification schemes that can identify patients at increased risk of bleeding events are, therefore, useful in clinical decision making.

Several risk stratification schemes for evaluation of short-term bleeding risks in patients with ACS have been developed from registry or trial cohorts. These include the CRUSADE and ACTION bleeding risk scores and a score developed by Mehran et al. based on data from the ACUITY and HORIZONS trials; female sex, renal impairment and anaemia are common to the three systems.553-555 Both the CRUSADE and ACTION bleeding risk scores predict in-hospital major bleeding; scores of ≤20, 21–30, 31–40, 41–50 and >50 are indicative of very low, low, moderate, high and very high bleeding risks.553, 555 The Mehran et al. bleeding risk score predicts 30-day non-coronary artery bypass bleeding; patients with scores of <10, 10–14, 15–19 and ≥20 are classified as low, moderate, high and very high risk of bleeding.554 Compared with the HAS-BLED scoring system to assess bleeding risk in patients with atrial fibrillation, the ACS bleeding risk scoring systems are less extensively validated.

  CRUSADE (2009)553 Mehran et al (2010)554 ACTION (2011)555
Derivation cohort 71,277 community-treated NSTEMI patients

13,819 patients with UA or NSTEMI enrolled in the ACUITY trial and 3602 patients with STEMI enrolled in the HORIZONS-AMI trial 72,313 patients with STEMI or NSTEMI admitted to hospitals participating in the ACTION registry

Validation cohort

17,857 patients 17,960 patients
Category Variable Score Variable Score Variable Score
Sex Male
Female
0
8
Male
Female
0
8
Male
Female
0
4

Baseline renal function

CrCl (ml/min)
≤15
>15–30
>30–60
>60–90
>90–120
>120
 

39
35
28
17
7
0
SCr(mg/dl)
<1.0
1.0–1.19
1.2–1.39
1.4–1.59
1.6–1.79
1.8–1.99
>2.0
 
0
2
3
5
6
8
10
SCr (mg/dl)
<0.8
0.8–1.59
1.6–1.99
2.0–2.99
3.0–3.99
4.0–4.99
5.0–5.99
≥6
On dialysis
 
0
1
2
4
6
8
10
11
11
Anaemic status Haematocrit (%)
<31
31–33.9
34–36.9
37–39.9
≥40
 

9
7
3
2
0
No anaemia
Anaemiaa
0

+6
Haemoglobin (g/dl)
<5
5–7.9
8–9.9
10–10.9
11–13.9
14–15.9
≥16
 


17
15
13
12
9
6
2
Signs of heart failure? No
Yes
0
7
No
Yes – HF only
Yes – HF with shock
0

3


15
Systolic blood pressure (mm Hg) ≤90
91–100
101–120
121–180
181–200
≥201
10
8
5
1
3
5
≤90
91–100
101–120
121–140
141–170
171–200
≥201
4
3
2
1
0
1
2
Prior vascular disease?

No
Yesb
0
6
No
Yesc
0
3
Heart rate (bpm) <70
71–80
81–90
91–100
101–110
111–120
≥120
0
1
3
6
8
10
11
≤40
41–60
61–70
71–80
81–100
101–110
111–120
121–130
131–150
≥151
0
2
3
5
6
8
9
11
12
14
Diabetes mellitus? No
Yes
0
6
No
Yes
0
3
Age (years) <50
50–59
60–69
70–79
≥80
0
3
6
9
12
≤40
41–50
51–60
61–70
71–80
81–90
≥91
0
1
2
3
4
5
6
Antithrom­botic medi­cations Heparin + GPI
Bivalirudin monotherapy
0

–5
Prior warfarin use?
No
Yes
 


0
2
ACS presentation/ ECG changes

STEMI
NSTEMI with raised biomarkers
NSTEMI with normal biomarkers
6
2


0
No ST changes
ST depression(or transient elevation)
ST elevation
0

3



7
Other criteria White blood cell count (109/l)
<10
10–11.99
12–13.99
14–15.99
16–17.99
18–19.99
>20
 



0
2
3
5
6
8
10
Body weight (kg)
≤50
51–70
71–100
101–120
121–140
≥141
 


5
4
3
2
1
0<

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aAnaemia defined as haemoglobin <13 g/dl in male patients and <12 g/dl in female patients; bprior vascular disease was defined as history of peripheral artery disease or prior stroke; cprior vascular disease was defined as previous peripheral artery disease.

ACS, acute coronary syndrome; bpm, beats per minute; CrCl, creatinine clearance; HF, heart failure; GPI, glycoprotein IIb/IIIa inhibitor; NSTEMI, non-ST-elevation myocardial infarction; SCr, serum creatinine; STEMI, ST-elevation myocardial infarction; UA, unstable angina.


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