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Prediction of severe bleeding after coronary surgery: the WILL-BLEED Risk Score
Fausto Biancari1, Debora Brascia, Francesco Onorati
1Prof. Fausto Biancari, Department of Surgery, Oulu University Hospital, PL 21, 90029 Oulu, Finland, Tel.: +358 40 7333 973, Fax: +358 8 315 2486,
Insights
A new WILL-BLEED score effectively identifies patients at high risk for severe bleeding after coronary artery bypass grafting (CABG). This simple tool aids in risk stratification, improving patient outcomes by predicting severe bleeding events.
Area of Science:
- Cardiovascular Surgery
- Anesthesiology
- Critical Care Medicine
Background:
- Severe perioperative bleeding after coronary artery bypass grafting (CABG) is a significant complication associated with adverse patient outcomes.
- Accurate prediction of severe bleeding is crucial for risk stratification and management in CABG patients.
- Existing bleeding risk scores may have limitations in predicting severe bleeding after CABG.
Purpose of the Study:
- To derive and validate an additive risk score, named WILL-BLEED, for the prediction of severe perioperative bleeding in patients undergoing CABG.
- To compare the predictive performance of the WILL-BLEED score against other established bleeding risk scores.
Main Methods:
- A risk score was derived from 2494 patients and validated in 1250 patients from the E-CABG registry.
- Severe bleeding was defined as E-CABG bleeding grades 2-3 (transfusion of >4 units of red blood cells or reoperation for bleeding).
- Independent predictors identified included preoperative anemia, female gender, reduced eGFR, potent antiplatelet drug use, critical preoperative state, acute coronary syndrome, and specific anticoagulants.
Main Results:
- The overall incidence of severe bleeding was 6.4%.
- The WILL-BLEED score demonstrated a significant association with increasing rates of severe bleeding in both derivation and validation cohorts (p<0.0001).
- The WILL-BLEED score exhibited superior discriminatory ability (AUC 0.725) compared to ACTION, CRUSADE, Papworth, TRUST, and TRACK scores, showing significant improvements in reclassification and discrimination.
Conclusions:
- The WILL-BLEED risk score is a simple and effective tool for stratifying patients at high risk of severe bleeding after CABG.
- This score offers improved predictive accuracy over existing scores, facilitating better clinical decision-making and patient management.
- Implementation of the WILL-BLEED score can aid in identifying high-risk individuals, potentially leading to tailored interventions and improved surgical outcomes.
Abstract:
Severe perioperative bleeding after coronary artery bypass grafting (CABG) is associated with poor outcome. An additive score for prediction of severe bleeding was derived (n=2494) and validated (n=1250) in patients from the E-CABG registry. Severe bleeding was defined as E-CABG bleeding grades 2-3 (transfusion of >4 units of red blood cells or reoperation for bleeding). The overall incidence of severe bleeding was 6.4 %. Preoperative anaemia (3 points), female gender (2 points), eGFR <45 ml/min/1.73 m2 (3 points), potent antiplatelet drugs discontinued less than five days (2 points), critical preoperative state (5 points), acute coronary syndrome (2 points), use of low-molecular-weight heparin/fondaparinux/unfractionated heparin (1 point) were independent predictors of severe bleeding. The WILL-BLEED score was associated with increasing rates of severe bleeding in both the derivation and validation cohorts (scores 0-3: 2.9 % vs 3.4 %; scores 4-6: 6.8 % vs 7.5 %; scores>6: 24.6 % vs 24.2 %, both p<0.0001). The WILL-BLEED score had a better discriminatory ability (AUC 0.725) for prediction of severe bleeding compared to the ACTION (AUC 0.671), CRUSADE (AUC 0.642), Papworth (AUC 0.605), TRUST (AUC 0.660) and TRACK (AUC 0.640) bleeding scores. The net reclassification index and integrated discrimination improvement using the WILL-BLEED score as opposed to the other bleeding scores were significant (p<0.0001). The decision curve analysis demonstrated a net benefit with the WILL-BLEED score compared to the other bleeding scores. In conclusion, the WILL-BLEED risk score is a simple risk stratification method which allows the identification of patients at high risk of severe bleeding after CABG.
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