Short-term performance of bleeding risk scores in anticoagulated older patients with acute pulmonary embolism

BACKGROUND: Older patients with pulmonary embolism (PE) are at increased risk of bleeding, which is associated with adverse outcomes, making early risk assessment particularly important. This study evaluated the short-term performance of commonly used bleeding risk scores in patients aged ≥65 years. METHODS: An analysis was conducted in a multicenter, prospective study of patients aged ≥65 years with PE receiving anticoagulation (NCT02943343, 2016). The performance of the PE-SARD, Kuijer, RIETE, BACS, and ATRIA scores was evaluated using the time-dependent area under the curve (AUC) analysis. Calibration was assessed with calibration plots. Sensitivity, specificity, and positive predictive values were calculated. The primary outcomes were major bleeding (MB) at 7 and 14 days. RESULTS: Among 3661 anticoagulated patients aged ≥65 years with acute PE, MB occurred in 18 (0.5%) and 36 (1.0%) patients at 7 and 14 days, respectively, and clinically relevant non-major bleeding (CRNMB) in 69 (1.9%) and 105 (2.9%) patients. Patients with bleeding events had higher mortality than those without bleeding. Discrimination for short-term MB was low to moderate across scores, with RIETE (AUC 0.76, 95% CI 0.65-0.87) and PE-SARD (AUC 0.74, 95% CI 0.63-0.85) showing the most consistent performance at 7 days. Overall discrimination declined at 14 days. All scores demonstrated limited ability to predict CRNMB, and no model showed a consistent net clinical benefit. CONCLUSIONS: In older patients with PE, bleeding risk scores showed low-to-moderate discrimination for short-term bleeding, with moderate early performance observed only in selected scores. None of the scores reliably identified CRNMB, highlighting the limitations of baseline risk assessment in acute care settings.