Assessment of bleeding in chronic liver disease and coagulopathy using the IMPROVE bleeding criteria

BACKGROUND: In this study, the authors utilized the IMPROVE (International Medical Prevention Registry on Venous Thromboembolism) bleeding definition to explore the safety profile of pharmacologic venous thromboembolism (VTE) prophylaxis in patients with chronic liver disease (CLD) and concurrent coagulopathy (INR ≥1.5). METHODS: A retrospective study was conducted on 193 adult patient admissions with a diagnosis of CLD and INR ≥1.5 not due to therapeutic anticoagulation. Patients were stratified based on their receipt of pharmacological thromboprophylaxis or not during hospitalization. The rates of overall bleeding, defined as the composite of major bleeding and clinically relevant non-major bleeding; major bleeding; and clinically relevant non-major bleeding, within 14 days of admission were evaluated. Secondary endpoints included the rates of thrombosis and mortality. RESULTS: The composite of overall bleeding occurred in 17.6% of the admissions. More patients in the group not receiving pharmacological thromboprophylaxis had overall bleeding (18.5% vs 10%), major bleeding (13.3% vs 10%), and clinically relevant non-major bleeding (14.5% vs 5%), with overlapping 95% CI. When stratified per pharmacological thromboprophylaxis status, IMPROVE bleeding risk score (BRS) ≥ 7 was associated with higher rates of overall bleeding, major bleeding, and clinically relevant non-major bleeding as compared to IMPROVE BRS <7, whether patients received or did not receive pharmacological thromboprophylaxis. The overall incidence of in-hospital mortality among our study population was 15.5%. Receiving pharmacological thromboprophylaxis was markedly associated with higher in-hospital mortality (OR = 16.58, 95% CI = 4.47-61.45). CONCLUSION: This study shows that the IMPROVE BRS calculated on admission may serve as a guide for omission of thromboprophylaxis in advanced CLD.