Prospective, multicenter validation of prediction scores for major bleeding in elderly patients with venous thromboembolism

Abstract

multicenter validation of prediction scores for major bleeding in elderly patients with venous thromboembolism. J Thromb Haemost 2013; 11: 435-43.Summary. Background: The Outpatient Bleeding Risk Index (OBRI) and the Kuijer, RIETE and Kearon scores are clinical prognostic scores for bleeding in patients receiving oral anticoagulants for venous thromboembolism (VTE). We prospectively compared the performance of these scores in elderly patients with VTE. Methods: In a prospective multicenter Swiss cohort study, we studied 663 patients aged ! 65 years with acute VTE. The outcome was a first major bleeding at 90 days. We classified patients into three categories of bleeding risk (low, intermediate and high) according to each score and dichotomized patients as high vs. low or intermediate risk. We calculated the area under the receiver-operating characteristic (ROC) curve, positive predictive values and likelihood ratios for each score. Results: Overall, 28 out of 663 patients (4.2%, 95% confidence interval [CI] 2.8-6.0%) had a first major bleeding within 90 days. According to different scores, the rate of major bleeding varied from 1.9% to 2.1% in low-risk, from 4.2% to 5.0% in intermediate-risk and from 3.1% to 6.6% in high-risk patients. The discriminative power of the scores was poor to moderate, with areas under the ROC curve ranging from 0.49 to 0.60 (P = 0.21). The positive predictive values and positive likelihood ratios were low and varied from 3.1% to 6.6% and from 0.72 to 1.59, respectively. Conclusion: In elderly patients with VTE, existing bleeding risk scores do not have sufficient accuracy and power to discriminate between patients with VTE who are at a high risk of short-term major bleeding and those who are not.

Predicting anticoagulant-related bleeding in patients with venous thromboembolism: a clinically oriented review

“…Common risk factors for bleeding events while on anticoagulant treatment include older age, female sex, history of bleeding, peptic ulcer, active cancer, hypertension, prior stroke, renal insufficiency, alcohol abuse, liver disease, targeted intensity of anticoagulant therapy and poor anticoagulant control [28][29][30][31][32][33][34][35][36][37][38][39]. The translation of these risk factors to clinical practice remains difficult, and physicians' estimates of the risk for anticoagulant-related bleeding are often inaccurate and poorly reproducible [40].…”

Status of Healthcare

“…The primary risk of anticoagulant therapy for VTE prophylaxis is bleeding, which accounts for 2 % to 3 % over a period of 3 months (Scherz et al 2013). Specific patient characteristics that are associated with an increased bleeding risk during anticoagulant therapy are renal failure, a history of bleeding and a simultaneous intake of platelet aggregation inhibitors (Decousus et al 2011;Falck-Ytter et al 2012).…”

“…These scores stratify the patients according to their bleeding risk. However, these risk scores have not been sufficiently tested in patients in orthopedic surgery (Falck-Ytter et al 2012), and do not differentiate between low and high bleeding risks precisely enough, particularly in older patients (≥ 65 years) (Scherz et al 2013). Hence, there is a need to develop and validate tools to stratify risks in patient populations after THA and TKA.…”

The optimal duration of anticoagulant therapy after unprovoked venous thromboembolism – still a challenging issue

“…Unfortunately, although many tools to predict bleeding risk during anticoagulation are available, none of them have been validated in the setting of VTE [36,37]. This assessment is particularly diffi cult in elderly patients.…”