Meta-Analysis of Bleeding Scores Performance for Acute Coronary Syndrome
Tom Kai Ming Wang1, Ojas Hrakesh Mehta2, Yi-Wen Becky Liao3
1Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand; Department of Medicine, University of Auckland, Auckland, New Zealand.
Insights
Bleeding risk scores for acute coronary syndrome (ACS) show moderate predictive ability. The ACTION score performed best, while CRUSADE was most studied and effective for specific patient subgroups.
Area of Science:
- Cardiology
- Clinical Risk Prediction
- Evidence Synthesis
Background:
- Bleeding is a significant complication in acute coronary syndrome (ACS) management.
- Potent antithrombotic therapies and invasive strategies increase bleeding risk.
- Risk models are underutilized for guiding ACS treatment decisions regarding bleeding.
Purpose of the Study:
- To compare the performance of various risk models in predicting bleeding complications in ACS patients.
- To evaluate the external validation of existing bleeding risk scores.
Main Methods:
- A systematic meta-analysis was conducted searching Medline, EMBASE, Cochrane, and Scopus from 1980 to December 2017.
- Seventeen studies with 18,155 patients were included after initial screening of 1,843 articles.
- Pooled analyses used random effects models to assess the predictive accuracy (C-statistics) of risk scores.
Main Results:
- The ACTION score demonstrated the highest pooled C-statistic (0.767) for predicting in-hospital major bleeding.
- The CRUSADE score (C=0.714) was the most extensively studied and showed better performance for radial access and invasive strategies.
- GRACE (C=0.689) and HAS-BLED (C=0.636) scores had lower predictive accuracy.
Conclusions:
- ACS-specific bleeding risk scores offer moderate predictive discrimination.
- The ACTION score shows the highest efficacy, while CRUSADE is a reliable, well-studied option, particularly for specific procedural approaches.
- Further research is needed to address study heterogeneities and expand validation of risk scores beyond CRUSADE.
Background:
Bleeding is a common and frequently devastating complication in acute coronary syndrome (ACS). It is critical to evaluate in the current era of ACS management involving invasive strategies and potent anti-thrombotics. Risk models remain under-utilised in this setting but may guide the choice and duration of therapy. We compared their performances for predicting bleeding in ACS patients in this meta-analysis.
Methods:
Medline, EMBASE, Cochrane and Scopus were searched for relevant articles from 1980 to 31 December 2017 assessing external validation of risk scores for bleeding after ACS. Two (2) authors independently reviewed the searched studies for eligibility, followed by pooled analyses using random effects models.
Results:
Amongst 1,843 articles searched, 73 full-texts were reviewed and 17 studies totalling 18,155 patients were included for analysis. C-statistics (95% confidence interval) for predicting in-hospital major bleeding by risk model were Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE) 0.714 (0.659-0.779), Acute Catheterization and Urgent Intervention Triage strategY (ACUITY) 0.711 (0.626-0.797), Acute Coronary Treatment and Intervention Outcomes Network (ACTION) 0.767 (0.737-0.797), Global Registry of Acute Coronary Events (GRACE) 0.689 (0.473-0.905) and HAS-BLED 0.636 (0.460-0.812). CRUSADE also predicted bleeding during medium-term follow-up c=0.704 (0.644-0.765). It performed better for radial versus femoral access (c=0.826 and 0.734), invasive versus non-invasive strategy (c=0.752 and 0.625) and similarly for ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI) (c=0.791 and 0.760). Heterogeneities of studies and paucity of studies assessing risk scores beyond CRUSADE were important limitations.
Conclusions:
Acute coronary syndrome-specific bleeding scores had moderate discrimination for bleeding, while the GRACE and HAS-BLED scores could not. The ACTION score had the highest pooled c-statistic, while the CRUSADE score was the most widely studied, and also performed better for invasive strategy and radial access subgroups.
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