Comparison of the Predictive Power of the CRUSADE, MEHRAN, and ACTION Bleeding Risk Scores in Patients With the Acute Coronary Syndrome

Document Type: Original Article

Authors

1 Department of Cardiology, Yazd Cardiovascular Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, IR Iran.

2 Department of Radiology, Faculty of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, IR Iran.

Abstract

Background: Various risk scores are used to predict the bleeding risk in patients with the acute coronary syndrome (ACS), including ACTION, CRUSADE, and MEHRAN. The purpose of the present study was to compare the accuracy of these 3 risk scores in the prediction of the bleeding risk in patients with the ACS. Methods: We studied 745 consecutive patients with the ACS undergoing coronary arteriography and calculated the ACTION, CRUSADE, and MEHRAN bleeding risk scores for all the patients. Then, we compared their prediction accuracy for major bleeding events and serious (major or minor) bleeding episodes with C-statistics. Results: The majority of the patients (72.6%) had non–ST-elevation myocardial infarction (NSTEMI), and the others (25.4%) had STEMI. The mean age of the patients was 62.55±12.12 years, and 62.4% were male. Bleeding complications were reported in 141 (18.9%) patients, with the catheterization site being the most frequent site of bleeding. The major bleeding rate was predicted in 29.1%, 28.4%, and 4.8% of the patients according to the CRUSADE, MEHRAN, and ACTION risk scores, respectively. The C-index values (AUC) for the ACTION, MEHRAN, and CRUSADE risk scores were 0.6182, 0.5413, and 0.6185, respectively. Pairwise comparisons between the scores showed no statistically significant differences in the discriminatory power between the ACTION and the CRUSADE (P=0.970); however, the differences between the CRUSADE and the MEHRAN (P=0.051) or between the ACTION and the MEHRAN (P=0.053) were near to significant. Conclusions: The bleeding risk score was predicted accurately by the ACTION, CRUSADE, and MEHRAN risk scores without significant differences among the 3 risk scores in our patients with the ACS undergoing coronary arteriography. These results showed that the predictive power was not excellent in any of the 3 risk scores.

Keywords


1.       Sanchis-Gomar F, Perez-Quilis C, Leischik R, Lucia A. Epidemiology of coronary heart disease and acute coronary syndrome. Annals of translational medicine. 2016;4(13).

2.       Vahedian-Azimi A, Miller AC, Hajiesmaieli M, Kangasniemi M, Alhani F, Jelvehmoghaddam H, et al. Cardiac rehabilitation using the Family-Centered Empowerment Model versus home-based cardiac rehabilitation in patients with myocardial infarction: A randomised controlled trial. Open Heart. 2016;3(1). English.

3.       Vahedian Azimi A, Sadeghi M, Movafegh A, Sorouri Zanjani R, Hasani D, Salehmoghaddam AR, et al. The relationship between perceived stress and the top five heart disease characteristics in patients with myocardial infarction. J Zanjan Univ Med Sci Health Serv. 2012;20(78). Persian.

4.       Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al. Executive Summary: Heart Disease and Stroke Statistics2016 Update: A Report the American Heart Association. Circulation. 2016 Jan 26;133(4):447-54. PubMed PMID: 26811276. Epub 2016/01/27. eng.

5.       Vahedian-Azimi A, Alhani F, Goharimogaddam K, Madani SJ, Naderi A, Hajiesmaeili M. Effect of family - Centered empowerment model on the quality of life in patients with myocardial infarction: A clinical trial study. J Nurs Educ. 2015;4(1):8-21. Persian.

6.       Kumar A, Cannon CP, editors. Acute coronary syndromes: diagnosis and management, part I. Mayo Clinic Proceedings; 2009: Elsevier.

7.       Cuisset T, Valgimigli M, Mudra H, Muller O, Wijns W, Huber K. Rationale and use of antiplatelet and antithrombotic drugs during cardiovascular interventions: May 2010 update. EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology. 2010 May;6(1):39-45. PubMed PMID: 20542796. Epub 2010/06/15. eng.

8.       Eikelboom JW, Mehta SR, Anand SS, Xie C, Fox KA, Yusuf S. Adverse impact of bleeding on prognosis in patients with acute coronary syndromes. Circulation. 2006;114(8):774-82.

9.       Alexander KP, Chen AY, Roe MT, Newby LK, Gibson CM, Allen-LaPointe NM, et al. Excess dosing of antiplatelet and antithrombin agents in the treatment of non–ST-segment elevation acute coronary syndromes. Jama. 2005;294(24):3108-16.

10.    Baber U, Kovacic J, Kini AS, Sharma SK, Dangas G, Mehran R. How serious a problem is bleeding in patients with acute coronary syndromes? Current cardiology reports. 2011;13(4):312-9.

11.    Bassand J-P. Impact of Bleeding and Transfusion in Acute Coronary Syndromes and Percutaneous Coronary Interventions. 2008.

12.    Kinnaird TD, Stabile E, Mintz GS, Lee CW, Canos DA, Gevorkian N, et al. Incidence, predictors, and prognostic implications of bleeding and blood transfusion following percutaneous coronary interventions. The American journal of cardiology. 2003;92(8):930-5.

13.    Abu-Assi E, Gracía-Acuña JM, Ferreira-González I, Peña-Gil C, Gayoso-Diz P, González-Juanatey JR. Evaluating the performance of the can rapid risk stratification of unstable angina patients suppress adverse outcomes with early implementation of the acc/aha guidelines (crusade) bleeding score in a contemporary Spanish cohort of patients with non–ST-segment elevation acute myocardial infarction. Circulation. 2010;121(22):2419-26.

14.    Chin CT, Chen AY, Wang TY, Alexander KP, Mathews R, Rumsfeld JS, et al. Risk adjustment for in-hospital mortality of contemporary patients with acute myocardial infarction: The Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry®–Get With The Guidelines (GWTG)™ acute myocardial infarction mortality model and risk score. American heart journal. 2011;161(1):113-22. e2.

15.    Mehran R, Pocock SJ, Stone GW, Clayton TC, Dangas GD, Feit F, et al. Associations of major bleeding and myocardial infarction with the incidence and timing of mortality in patients presenting with non-ST-elevation acute coronary syndromes: a risk model the ACUITY trial. European heart journal. 2009;30(12):1457-66.

16.    Mehran R, Pocock SJ, Nikolsky E, Clayton T, Dangas GD, Kirtane AJ, et al. A risk score to predict bleeding in patients with acute coronary syndromes. Journal of the American College of Cardiology. 2010;55(23):2556-66.

17.    Moscucci M, Fox KA, Cannon CP, Klein W, López-Sendón J, Montalescot G, et al. Predictors of major bleeding in acute coronary syndromes: the Global Registry of Acute Coronary Events (GRACE). European heart journal. 2003;24(20):1815-23.

18.    Abu-Assi E, Raposeiras-Roubin S, Lear P, Cabanas-Grandío P, Girondo M, Rodríguez-Cordero M, et al. Comparing the predictive validity of three contemporary bleeding risk scores in acute coronary syndrome. European Heart Journal: Acute Cardiovascular Care. 2012;1(3):222-31.

19.    Hamm CW, Bassand J-P, Agewall S, Bax J, Boersma E, Bueno H, et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). European heart journal. 2011;32(23):2999-3054.

20.    Flores-Rios X, Couto-Mallon D, Rodriguez-Garrido J, Garcia-Guimaraes M, Gargallo-Fernandez P, Pinon-Esteban P, et al. Comparison of the performance of the CRUSADE, ACUITY-HORIZONS, and ACTION bleeding risk scores in STEMI undergoing primary PCI: insights a cohort of 1391 patients. European heart journal Acute cardiovascular care. 2013 Mar;2(1):19-26. PubMed PMID: 24062930. Pubmed Central PMCID: Pmc3760576. Epub 2013/09/26. eng.

21.    Kadakia MB, Desai NR, Alexander KP, Chen AY, Foody JM, Cannon CP, et al. Use of anticoagulant agents and risk of bleeding among patients admitted with myocardial infarction: a report the NCDR ACTION Registry–GWTG (National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With the Guidelines). JACC: Cardiovascular Interventions. 2010;3(11):1166-77.

22.    Van de Werf F, Bax J, Betriu A, Blomstrom-Lundqvist C, Crea F, Falk V, et al. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation. Giornale italiano di cardiologia (2006). 2009;10(7):450.

23.    Ariza-Solé A, Sánchez-Elvira G, Sánchez-Salado JC, Lorente-Tordera V, Salazar-Mendiguchía J, Sánchez-Prieto R, et al. CRUSADE bleeding risk score validation for ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention. Thrombosis research. 2013;132(6):652-8.

24.    Correia LC, Merelles S, Vasconcelos A, Cerqueira T, Reis T, Esteves C, et al. Validation of a score for predicting bleeding events during acute coronary syndromes. Arquivos brasileiros de cardiologia. 2010;95(4):457-63.

25.    Wang R, Mei B, Liao X, Lu X, Yan L, Lin M, et al. Determination of risk factors affecting the in-hospital prognosis of patients with acute ST segment elevation myocardial infarction after percutaneous coronary intervention. BMC cardiovascular disorders. 2017;17(1):243.

26.  Subherwal S, Bach RG, Chen AY, Gage BF, Rao SV, Newby LK, et al. Baseline risk of major bleeding in non–ST-segment–elevation myocardial infarction. Circulation. 2009;119(14):1873-82.