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Predictive scores for major bleeding after coronary artery bypass surgery in low operative risk patients
Antonio Salsano1, Carmelo Dominici2, Antonio Nenna2
1Division of Cardiac Surgery, San Martino University Hospital IRCCS, University of Genoa, Genoa, Italy - ant.salsano@gmail.com.
Insights
The WILL-BLEED score best predicts severe bleeding after coronary artery bypass grafting (CABG) in low-risk patients. This finding is crucial for improving patient outcomes and managing transfusion risks in cardiac surgery.
Area of Science:
- Cardiovascular Surgery
- Transfusion Medicine
- Clinical Risk Prediction
Background:
- Cardiac surgery frequently involves perioperative bleeding, increasing the need for allogeneic blood transfusions.
- Several risk scores have been developed to predict severe bleeding events.
- The study focuses on patients undergoing coronary artery bypass grafting (CABG) with low estimated operative risk.
Purpose of the Study:
- To compare the predictive performance of the WILL-BLEED score against CRUSADE, PAPWORTH, TRUST, TRACK, and ACTION scores for major bleeding after CABG.
- To evaluate the WILL-BLEED score's efficacy specifically in low-risk patient populations.
- To assess the association between severe bleeding and in-hospital mortality.
Main Methods:
- A multicenter observational study involving 1391 patients undergoing isolated CABG between July 2015 and January 2018.
- Prospective evaluation of the primary endpoint: performance of established bleeding risk scores.
- Secondary endpoint: assessment of in-hospital mortality rates.
Main Results:
- The WILL-BLEED score demonstrated the best predictive performance, indicated by the highest c-index (AUC: 0.658).
- Reclassification analysis revealed that CRUSADE, PAPWORTH, TRACK, and ACTION scores performed worse than WILL-BLEED in this cohort.
- Severe bleeding was significantly associated with increased early mortality (OR: 13.26; P<0.001).
Conclusions:
- Severe bleeding post-CABG is a significant adverse event with substantial mortality implications.
- The WILL-BLEED score is the most effective tool for predicting severe-massive bleeding after CABG in low-risk patients.
- The TRUST score is a viable alternative, though WILL-BLEED shows superior performance.
Background:
Cardiac surgery is associated with perioperative bleeding and carries high risk of allogeneic blood transfusion. Recently new scores for prediction of severe bleeding have been developed. This study aims to compare the WILL-BLEED, CRUSADE, PAPWORTH, TRUST, TRACK and ACTION scores in predicting major bleeding after CABG in patients with low estimated operative risk.
Methods:
A multicenter observational study included 1391 patients who underwent isolated CABG from July 2015 to January 2018. We tested the hypothesis that the WILL-BLEED score, specifically designed for CABG, would perform at least as well as the CRUSADE, PAPWORTH, TRUST, TRACK and ACTION scores in predicting postoperative major bleeding in low operative risk patients. The primary endpoint was the performance of known bleeding risk scores after CABG. The secondary endpoint was the evaluation of in-hospital mortality.
Results:
Mean age was 68.2±9.4 years and median Euroscore II value was 1.69% (IQR 1.15-2.81%). Mean blood losses in the first 12 postoperative hours was 339.75 mL. Seventy-three (5.2%) subjects underwent administration of blood products. The rate of severe-massive bleeding according to UDPB grades 3-4 was 1.5%. WILL-BLEED, TRUST, TRACK and ACTION scores were significantly associated with severe postoperative bleeding. WILL-BLEED presented the best c-index (AUC: 0.658; 95% CI: 0.600,0.716). Reclassification analysis showed a worsening in sensitivity and significant negative reclassification of CRUSADE, PAPWORTH, TRACK and ACTION scores when compared with WILL-BEED. The combination of WILL-BLEED and TRUST scores improved the prediction ability (AUC: 0.673; 95% CI: 0.615-0.732). Overall in-hospital mortality was 1.65%. Early mortality in patients with severe versus no-severe bleeding was found to be 11.8% vs. 1.0% Severe bleeding (OR: 13.26; P value<0.001) was found to be significantly associated with early mortality.
Conclusions:
Severe bleeding after CABG is a harmful event associated with adverse outcomes. WILL-BLEED Score has the better performance in predicting severe-massive bleeding after CABG. The TRUST Score, although suboptimal, represents a valuable alternative in this setting.
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