ABC score: a new risk score that accurately predicts mortality in acute upper and lower gastrointestinal bleeding: an international multicentre study

Abstract

ObjectivesExisting scores are not accurate at predicting mortality in upper (UGIB) and lower (LGIB) gastrointestinal bleeding. We aimed to develop and validate a new pre-endoscopy score for predicting mortality in both UGIB and LGIB.Design and settingInternational cohort study. Patients presenting to hospital with UGIB at six international centres were used to develop a risk score for predicting mortality using regression analyses. The score’s performance in UGIB and LGIB was externally validated and compared with existing scores using four international datasets. We calculated areas under receiver operating characteristics curves (AUROCs), sensitivities, specificities and outcome among patients classified as low risk and high risk.Participants and resultsWe included 3012 UGIB patients in the development cohort, and 4019 UGIB and 2336 LGIB patients in the validation cohorts. Age, Blood tests and Comorbidities (ABC) score was closer associated with mortality in UGIB and LGIB (AUROCs: 0.81–84) than existing scores (AUROCs: 0.65–0.75; p≤0.02). In UGIB, patients with low ABC score (≤3), medium ABC score (4–7) and high ABC score (≥8) had 30-day mortality rates of 1.0%, 7.0% and 25%, respectively. Patients classified low risk using ABC score had lower mortality than those classified low risk with AIMS65 (threshold ≤1) (1.0 vs 4.5%; p<0.001). In LGIB, patients with low, medium and high ABC scores had in-hospital mortality rates of 0.6%, 6.3% and 18%, respectively.ConclusionsIn contrast to previous scores, ABC score has good performance for predicting mortality in both UGIB and LGIB, allowing early identification and targeted management of patients at high or low risk of death.

Comparison of Risk Scoring Systems in Hospitalised Patients who Develop Upper Gastrointestinal Bleeding

“…In our study, 15% of hospitalised patients who develop UGIB died within the 30 days of bleeding onset. This very high mortality rate is consistent with previous studies examining similar patients, 11,12,15,16 and more than twice as high as community‐based patients presenting to hospital with UGIB 7,9 . The difference in mortality is probably due to hospitalised patients who develop UGIB being older and more comorbid, both of which are strong predictors of mortality 4,7,11,12 .…”

“…Although risk assessment scores have been used in clinical practice for many years there has been a low uptake into everyday clinical practice likely due to physician uncertainty about which score should be used to predict particular outcomes in different patient groups. The ABC score has already been shown to be the most accurate at predicting mortality in patients presenting to hospital with UGIB 7 . Our study's results show the ABC score is a ‘one‐size‐fits‐all’ score that can be accurately used in all patients with UGIB meaning its use in clinical practice will likely increase.…”

“…This study also found these scores poorly predict mortality (all scores AUROC < 0.8), an outcome which is useful when considering prognosis and level of care requirements 9 . Subsequently, Laursen et al developed and validated the ABC score, a pre‐endoscopy score which accurately predicts 30‐day mortality (AUROC 0.81) 7 . Of note, studies assessing the utility of these scoring systems have excluded patients hospitalised for another reason, such as infection or surgery, who then develop UGIB (sometimes referred to as secondary or nosocomial UGIB), or analysed them in combination with patients presenting to hospital with UGIB.…”

“…Using the predefined ABC score cut‐offs, 7 patients with an ABC score of ≤3 (27% of patients) had a very low (1.6%) risk of death within 30 days, patients with a score of 4 to 7 (46% of patients) had a mortality rate of 7.5% and patients with a score ≥8 (27% of patients) had a very high mortality rate (42%).…”

“…Pre‐endoscopy scores, which are calculated at presentation to hospital with UGIB, are used to predict need for hospital‐based intervention (transfusion, endoscopic treatment, radiological embolisation or surgery) and 30‐day mortality risk. They include the Glasgow Blatchford score (GBS), AIMS65 (albumin < 30g/L (A), INR > 1.5 (I), altered mental state (M), systolic blood pressure ≤ 90 (S) and age > 65 years (65)) score, admission Rockall score and ABC (age (A), blood tests (B), comorbidities (C)) score 4‐7 . While the post‐endoscopy scores, Rockall score and Progetto Nazionale Emorragia Digestive (PNED) score, require endoscopic findings to predict mortality and risk of rebleeding 5,8 …”