The American College of Chest Physician score to assess the risk of bleeding during anticoagulation in patients with venous thromboembolism

Abstract

Background The American College of Chest Physicians (ACCP) guideline proposes a score to decide on extended anticoagulation after an unprovoked venous thromboembolism (VTE). Methods We investigated the ACCP score to predict bleeding risk in an inception cohort of 2263 patients on long-term anticoagulation (1522 treated with vitamin K antagonists [VKAs] and the remaining with direct oral anticoagulants [DOACs]) belonging to the Italian START2 Register. Results More than half the patients were categorized as high risk; nevertheless, a higher proportion received anticoagulation for > 1 year compared with those in the low-risk category. For 3130 years (median 12 [interquartile range 6, 24] months), 48 bleeding outcomes occurred (1.53%/year) in the cohort (1.7%/year and 0.95%/year in high- and low-risk categories, respectively). The c-statistic of the ACCP score was 0.55 (0.48-0.63), 0.50 (0.42-0.58) and 0.56 (0.48-0.64) in low-, moderate- and high-risk categories, respectively. The bleeding incidence was higher during the first 90 days of treatment (3.0%/year) than afterwards (1.2%/year; relative risk (RR), 2.5 [1.3-4.7]), and similar among the three categories. The bleeding rate was not different during the initial 3 months of treatment in patients receiving VKAs or DOACs; it was, however, lower in the latter patients in the subsequent period (0.5%/year vs. 1.4%/year, respectively). Conclusion The bleeding rate during extended treatment was rather low in our patients. ACCP score had insufficiently predictive value for bleeding and cannot be used to guide decisions on extended treatment. New prediction tools for bleeding risk during anticoagulant treatments (including DOACs) are required.

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

“…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.…”

Short-term versus extended anticoagulant treatment for unprovoked venous thromboembolism: A survey on guideline adherence and physicians' considerations

“…older age), but how this affects an individual risk is hard to translate into precise percentages. Second, guidelines recommend to use the American College of Chest Physicians (ACCP) risk score to classify patients at low or high risk of bleeding [3,4].However, this ACCP score has poor predictive performance and is therefore insufficiently reliable to guide decisions on extended treatment [7]. Other risk scores for bleeding are also considered insufficiently valid [3][4][5].…”

The American College of Chest Physician score to assess the risk of bleeding during anticoagulation in patients with venous thromboembolism: reply

“…The American College of Chest Physician score to assess the risk of bleeding during anticoagulation in patients with venous thromboembolism: reply We would like to thank Brown et al for the attention that they gave to our study on the American College of Chest Physicians (ACCP) bleeding score [1]. We have read with interest their communication, and agree with most of their comments.…”

“…Comparison of high-risk patient prevalence according to the risk scores for bleeding and the rates of bleeding events recorded in the corresponding patients, calculated by use of the dataset of patient results used for our article on the American College of Chest Physicians (ACCP) score[1] …”