Why the study?
Bleeding risk prediction scores were validated for use with vitamin K antagonists and parenteral anticoagulants, but evidence for their use with direct oral anticoagulants is lacking.
Do established bleeding risk prediction scores accurately predict major bleeding in patients on direct oral anticoagulants?
Do established bleeding risk prediction scores accurately predict major bleeding in patients on direct oral anticoagulants?
Established bleeding risk prediction scores have limited diagnostic accuracy (AUC < 0.7) for predicting major bleeding in patients on DOACs, suggesting caution when applying them to this population.
Bleeding risk scores warrant cautious use in DOAC patients; leaves open whether they meaningfully improve outcomes over clinical judgment.
BACKGROUND: Direct oral anticoagulants (DOACs) offer many benefits over vitamin K antagonists (VKAs) but still carry a significant risk of major bleeding. Bleeding risk prediction scores such as the Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile International Normalized Ratio, Elderly, and Drugs/Alcohol (HAS-BLED), Hepatic or Renal Disease, Ethanol Abuse, Malignancy, Older Age, Reduced Platelet Count or Function, Re-Bleeding, Hypertension, Anemia, Genetic Factors, Excessive Fall Risk, and Stroke (HEMORR2HAGES), Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA), Registro Informatizado Enfermedad TromboEmbólica (RIETE), and CHEST scores were validated or evaluated for use with VKAs and parenteral anticoagulants, but evidence for use with DOACs is lacking. OBJECTIVE: This study aims to evaluate bleeding risk prediction scores for DOAC patients presenting with major bleeding. METHODS: A retrospective analysis of patients presenting from 2015 to 2018 was performed. Patients were separated into bleed and nonbleed groups. The primary objective was to assess the diagnostic accuracy of the bleeding risk prediction scores utilizing the receiver operating characteristic (ROC) curve. RESULTS: HAGES, ATRIA, RIETE, and CHEST scores were 0.645, 0.675, 0.580, 0.638, and 0.667, respectively. CONCLUSION AND RELEVANCE: HAGES, RIETE, and CHEST scores were found to have sufficient diagnostic accuracy for predicting risk of major bleeding in our study population; however, no score was identified as having an AUC greater than 0.7. Caution may be considered when utilizing these scores for patients on DOACs.
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Tchen et al. (2020) studied this question.
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