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

Palareti, Gualtiero; Antonucci, Emilia; Ageno, Walter; Mastroiacovo, Daniela; Poli, Daniela; Tosetto, Alberto

doi:10.1111/jth.14300

Cited by 6 publications

(6 citation statements)

References 9 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Previous external validation studies in the general VTE population also showed poor to moderate discrimination. 28 39 40 41 42 43 44 This may be explained by methodological limitations, as all model derivation studies were considered to be at high risk of bias according to the PROBAST tool. 27 36…”

Section: Discussionmentioning

confidence: 99%

Estimating Bleeding Risk in Patients with Cancer-Associated Thrombosis: Evaluation of Existing Risk Scores and Development of a New Risk Score

et al. 2021

View full text Add to dashboard Cite

Background Bleeding risk is highly relevant for treatment decisions in cancer-associated thrombosis (CAT). Several risk scores exist, but have never been validated in patients with CAT and are not recommended for practice. Objectives To compare methods of estimating clinically relevant (major and clinically relevant nonmajor) bleeding risk in patients with CAT: (1) existing risk scores for bleeding in venous thromboembolism, (2) pragmatic classification based on cancer type, and (3) new prediction model. Methods In a posthoc analysis of the Hokusai VTE Cancer study, a randomized trial comparing edoxaban with dalteparin for treatment of CAT, seven bleeding risk scores were externally validated (ACCP-VTE, HAS-BLED, Hokusai, Kuijer, Martinez, RIETE, and VTE-BLEED). The predictive performance of these scores was compared with a pragmatic classification based on cancer type (gastrointestinal; genitourinary; other) and a newly derived competing risk-adjusted prediction model based on clinical predictors for clinically relevant bleeding within 6 months after CAT diagnosis with nonbleeding-related mortality as the competing event (“CAT-BLEED”). Results Data of 1,046 patients (149 events) were analyzed. Predictive performance of existing risk scores was poor to moderate (C-statistics: 0.50–0.57; poor calibration). Internal validation of the pragmatic classification and “CAT-BLEED” showed moderate performance (respective C-statistics: 0.61; 95% confidence interval [CI]: 0.56–0.66, and 0.63; 95% CI 0.58–0.68; good calibration). Conclusion Existing risk scores for bleeding perform poorly after CAT. Pragmatic classification based on cancer type provides marginally better estimates of clinically relevant bleeding risk. Further improvement may be achieved with “CAT-BLEED,” but this requires external validation in practice-based settings and with other DOACs and its clinical usefulness is yet to be demonstrated.

show abstract

Section: Discussionmentioning

confidence: 99%

Estimating Bleeding Risk in Patients with Cancer-Associated Thrombosis: Evaluation of Existing Risk Scores and Development of a New Risk Score

et al. 2021

View full text Add to dashboard Cite

show abstract

“…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.…”

Section: Discussionmentioning

confidence: 99%

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

Klok

Presles

Tromeur

et al. 2019

Research and Practice in Thrombosis and Haemostasis

View full text Add to dashboard Cite

Introduction VTE‐BLEED is a validated score for identification of patients at increased risk of major bleeding during extended anticoagulation for venous thromboembolism (VTE). It is unknown whether VTE‐BLEED high‐risk patients also have an increased risk for recurrent VTE, which would limit the potential usefulness of the score. Methods This was a post hoc analysis of the randomized, double‐blind, placebo‐controlled PADIS‐PE trial that randomized patients with a first unprovoked pulmonary embolism (PE) initially treated during 6 months to receive an additional 18‐month of warfarin vs. placebo. The primary outcome of this analysis was recurrent VTE during 2‐year follow‐up after anticoagulant discontinuation, that is, after the initial 6‐month treatment in the placebo arm and after 24 months of anticoagulation in the active treatment arm. This rate, adjusted for study treatment allocation, was compared between patients in the high‐ vs. low‐risk VTE‐BLEED group. Results In complete case analysis (n = 308; 82.4% of total population), 89 (28.9%) patients were classified as high risk; 44 VTE events occurred after anticoagulant discontinuation during 668 patient‐years. The cumulative incidence of recurrent VTE was 16.4% (95% confidence interval [CI], 10.0%‐26.1%; 14 events) and 14.6% (95% CI, 10.4%‐20.3%; 30 events) in the high‐risk and low‐risk VTE‐BLEED groups, respectively, for an adjusted hazard ratio of 1.16 (95% CI, 0.62‐2.19). Conclusion In this study, patients with unprovoked PE classified at high risk of major bleeding by VTE‐BLEED did not have a higher incidence of recurrent VTE after cessation of anticoagulant therapy, supporting the potential yield of the score for making management decisions on the optimal duration of anticoagulant therapy.

show abstract

“…It should be noted that most of these studies were either retrospective or post hoc and did not involve independent adjudication of bleeding events. 18,34,35,37,[42][43][44][45][46][47][48][49][50][51][52][53][54][55][56][57] Moreover, only very few aimed specifically at the most relevant treatment period beyond the first 3 months. Of note, reporting measures of discrimination (ie, C-statistic) will always be important for a prediction model, but decision-analytic measures, such as absolute risks and risk differences between risk categories, are at least as relevant if the model is to be used for making clinical decisions: in most studies, the high-risk class of the different scores indeed involved a clearly higher risk than the low-risk class, even despite poor calibration statistics, indicating at least some clinical usefulness.…”

Section: How To Identify Modifiable Risk Factors For Bleedingmentioning

confidence: 99%

How I assess and manage the risk of bleeding in patients treated for venous thromboembolism

Klok

Huisman

2020

Blood

View full text Add to dashboard Cite

For patients with venous thromboembolism (VTE), prediction of bleeding is relevant throughout the course of treatment, although the means and goal of this prediction differ between the subsequent stages of treatment: treatment initiation, hospital discharge, 3-month follow-up, and long-term follow-up. Even in the absence of fully established risk prediction schemes and outcome studies using a prediction scheme for treatment decisions, the present evidence supports screening for and targeting of modifiable risk factors for major bleeding, as well as the application of decision rules to identify patients at low risk of bleeding complications, in whom long-term anticoagulant treatment is likely safe. Moving forward, prediction tools need to be incorporated in well-designed randomized controlled trials aiming to establish optimal treatment duration in patients at high risk of recurrent VTE. Moreover, the benefit of their longitudinal assessment rather than application as stand-alone baseline assessments should be studied, because changes in bleeding risk over time likely constitute the best predictor of major bleeding. We provide the state-of-the-art of assessing and managing bleeding risk in patients with acute VTE and highlight a practical approach for daily practice illustrated by 2 case scenarios.

show abstract

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

Cited by 6 publications

References 9 publications

Estimating Bleeding Risk in Patients with Cancer-Associated Thrombosis: Evaluation of Existing Risk Scores and Development of a New Risk Score

Estimating Bleeding Risk in Patients with Cancer-Associated Thrombosis: Evaluation of Existing Risk Scores and Development of a New Risk Score

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

How I assess and manage the risk of bleeding in patients treated for venous thromboembolism

Contact Info

Product

Resources

About