Original article
Efficacy of Bleeding Risk Scores in Elderly Patients with Acute Coronary SyndromesEficacia de los scores de riesgo hemorrágico en el paciente anciano con síndrome coronario agudo

https://doi.org/10.1016/j.rec.2013.10.008Get rights and content

Abstract

Introduction and objectives

The incidence of acute coronary syndromes is high in the elderly population. Bleeding is associated with a poorer prognosis in this clinical setting. The available bleeding risk scores have not been validated specifically in the elderly. Our aim was to assess predictive ability of the most important bleeding risk scores in patients with acute coronary syndrome aged ≥ 75 years.

Methods

We prospectively included consecutive acute coronary syndromes patients. Baseline characteristics, laboratory findings, and hemodynamic data were collected. In-hospital bleeding was defined according to CRUSADE, Mehran, ACTION, and BARC definitions. CRUSADE, Mehran, and ACTION bleeding risk scores were calculated for each patient. The ability of these scores to predict major bleeding was assessed by binary logistic regression, receiver operating characteristic curves, and area under the curves.

Results

We included 2036 patients, with mean age of 62.1 years; 369 patients (18.1%) were ≥ 75 years. Older patients had higher bleeding risk (CRUSADE, 42 vs 22; Mehran, 25 vs 15; ACTION, 36 vs 28; P<.001) and a slightly higher incidence of major bleeding events (CRUSADE bleeding, 5.1% vs 3.8%; P=.250). The predictive ability of these 3 scores was lower in the elderly (area under the curve, CRUSADE: 0.63 in older patients, 0.81 in young patients; P = .027; Mehran: 0.67 in older patients, 0.73 in younger patients; P = .340; ACTION: 0.58 in older patients, 0.75 in younger patients; P = .041).

Conclusions

Current bleeding risk scores showed poorer predictive performance in elderly patients with acute coronary syndromes than in younger patients.

Resumen

Introducción y objetivos

La incidencia de síndrome coronario agudo en pacientes ancianos es elevada. Las complicaciones hemorrágicas empeoran el pronóstico en este escenario; a pesar de ello, los scores de riesgo hemorrágico disponibles no han sido validados específicamente en este subgrupo. Nuestro objetivo es analizar la capacidad predictiva de los principales scores de riesgo hemorrágico en pacientes de edad ≥ 75 años.

Métodos

Inclusión prospectiva de pacientes con síndrome coronario agudo consecutivos. Se registraron características basales, datos analíticos y hemodinámicos y la incidencia intrahospitalaria de hemorragias utilizando las definiciones CRUSADE, Mehran, ACTION y BARC. Se calcularon los scores CRUSADE, Mehran y ACTION de cada paciente y se analizó su capacidad predictiva de hemorragias mediante regresión logística binaria, cálculo de curvas receiver operating characteristic y áreas bajo la curva.

Resultados

Se incluyó a 2.036 pacientes con una media de edad de 62,1 años; el 18,1% (369 pacientes) era ≥ 75 o más años. Este subgrupo presentaba mayor riesgo hemorrágico (CRUSADE, 42 frente a 22; Mehran, 25 frente a 15; ACTION, 36 frente a 28; p < 0,001) y una incidencia de hemorragias mayores ligeramente superior (CRUSADE, el 5,1 frente al 3,8%; p = 0,250). La capacidad predictiva de los tres scores fue inferior en los ancianos (área bajo la curva, CRUSADE: ancianos, 0,63; jóvenes, 0,81; p = 0,027; Mehran: ancianos, 0,67; jóvenes, 0,73; p = 0,340; ACTION: ancianos, 0,58; jóvenes, 0,75; p = 0,041).

Conclusiones

Los scores de riesgo hemorrágico actualmente disponibles mostraron en el paciente anciano con síndrome coronario agudo un rendimiento claramente inferior al observado en pacientes más jóvenes.

Section snippets

INTRODUCTION

Bleeding complications are associated with a less favorable prognosis in patients with an acute coronary syndrome (ACS).1, 2, 3 Clinical practice guidelines4, 5 recommend basing therapy strategies for these patients on the risk of both ischemic and bleeding events. Hence, over the last few years, various risk scores have been designed to predict bleeding complications in this scenario.6, 7, 8

The incidence of acute myocardial infarction increases with age and is particularly elevated in the

Study Design

This is a prospective, observational study performed in a single referral hospital for ACS. We prospectively included all ACS patients admitted to the coronary unit of our center between October 2009 and June 2012. The diagnosis and therapeutic management of the patients was carried out in accordance with current recommendations.4, 5

Definitions and Data Collection

Trained staff prospectively compiled the study data using a standardized questionnaire. They recorded the patients’ baseline characteristics, clinical history,

RESULTS

The study included 2036 patients (mean age, 62.1 years), 1570 (77.1%) of whom were men; 369 patients (18.1%) were aged ≥ 75 years. The characteristics of the study population according to age are shown in Table 1.

In general, elderly patients had a larger number of cardiovascular risk factors and other comorbidities, a greater incidence of signs of heart failure, and significantly lower glomerular filtration and hemoglobin values at admission than the remaining patients. In addition, coronary

DISCUSSION

Two main findings were obtained from this study: a) the incidence of bleeding complications in patients ≥ 75 years was slightly higher than that of younger patients, with significant differences in the site of bleeding, but no differences in bleeding severity, and b) the main instruments currently available for bleeding risk stratification clearly show poorer performance in patients of more advanced age.

The evident prognostic implications of bleeding complications in ACS patients1, 2, 3 confers

CONCLUSIONES

Elderly patients in our series had a higher risk of bleeding and a slightly higher incidence of bleeding complications than younger patients. This study is the first to report suboptimal performance of the main bleeding risk scores in elderly patients with ACS. Assessment of factors such as patient frailty and comorbidity could, in our opinion, contribute to improving the predictive ability of these tools in this clinical setting.

CONFLICTS OF INTERESTS

None declared.

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