The ORBIT bleeding score: a simple bedside score to assess bleeding risk in atrial fibrillation

Abstract

BackgroundTherapeutic decisions in atrial fibrillation (AF) are often influenced by assessment of bleeding risk. However, existing bleeding risk scores have limitations.ObjectivesWe sought to develop and validate a novel bleeding risk score using routinely available clinical information to predict major bleeding in a large, community-based AF population.MethodsWe analysed data from Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF), a prospective registry that enrolled incident and prevalent AF patients at 176 US sites. Using Cox proportional hazards regression, we identified factors independently associated with major bleeding among patients taking oral anticoagulation (OAC) over a median follow-up of 2 years (interquartile range = 1.6–2.5). We also created a numerical bedside risk score that included the five most predictive risk factors weighted according to their strength of association with major bleeding. The predictive performance of the full model, the simple five-item score, and two existing risk scores (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile INR, elderly, drugs/alcohol concomitantly, HAS-BLED, and anticoagulation and risk factors in atrial fibrillation, ATRIA) were then assessed in both the ORBIT-AF cohort and a separate clinical trial population, Rivaroxaban Once-daily oral direct factor Xa inhibition compared with vitamin K antagonism for prevention of stroke and embolism trial in atrial fibrillation (ROCKET-AF).ResultsAmong 7411 ORBIT-AF patients taking OAC, the rate of major bleeding was 4.0/100 person-years. The full continuous model (12 variables) and five-factor ORBIT risk score (older age [75+ years], reduced haemoglobin/haematocrit/history of anaemia, bleeding history, insufficient kidney function, and treatment with antiplatelet) both had good ability to identify those who bled vs. not (C-index 0.69 and 0.67, respectively). These scores both had similar discrimination, but markedly better calibration when compared with the HAS-BLED and ATRIA scores in an external validation population from the ROCKET-AF trial.ConclusionsThe five-element ORBIT bleeding risk score had better ability to predict major bleeding in AF patients when compared with HAS-BLED and ATRIA risk scores. The ORBIT risk score can provide a simple, easily remembered tool to support clinical decision making.

2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

“…13) porównano z warfaryną w indywidualnie dobieranej dawce [405]. Edoksaban w dawce [388] e Czynnik uwzględniony w skali ABC (obejmującej wiek, biomarkery, wywiady kliniczne) [387] www.kardiologiapolska.pl 60 mg raz na dobę był nie gorszy niż warfaryna (tab. 13).…”

Is the ORBIT Bleeding Risk Score Superior to the HAS-BLED Score in Anticoagulated Atrial Fibrillation Patients?

“…This bleeding score is claimed to have a statistically superior ability in predicting major bleeding in anticoagulated AF patients, when compared with the HAS-BLED and ATRIA bleeding risk scores. 13 Our objective was to test the hypothesis that the ORBIT score is superior to the HAS-BLED score for predicting major bleeding and death in "real world" AF patients who were anticoagulated with acenocoumarol. Second, we analyzed if the HAS-BLED score performed better in identifying AF patients who are at low risk of bleeding.…”

Bleeding Risk Scores in Atrial Fibrillation: Helpful or Harmful?

“…There is a paucity of evidence supporting the use of bleeding risk scores in patients on DOACs. GARFIELD‐AF and ORBIT‐AF had very few patients on DOACs 4, 13. Most bleeding risk scores were validated with warfarin 2, 4, 5, 13.…”

“…GARFIELD‐AF and ORBIT‐AF had very few patients on DOACs 4, 13. Most bleeding risk scores were validated with warfarin 2, 4, 5, 13. In a large study of patients on DOACs in a Danish registry, HAS‐BLED, ATRIA, and ORBIT‐AF were equally moderately predictive (C index: 0.58–0.61) 14.…”