Letter to the Editor
Bleeding risk assessment and comorbidities in elderly patients with acute coronary syndromes
Avaliação do risco hemorrágico e comorbilidades em doentes idosos com síndromes coronárias agudas
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array:1 [ "en" => array:9 [ "pii" => "S0870255116000755" "doi" => "10.1016/j.repc.2015.10.010" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255116000755?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204916300113?idApp=UINPBA00004E" "url" => "/21742049/0000003500000004/v2_201703300127/S2174204916300113/v2_201703300127/en/main.assets" ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Bleeding risk assessment and comorbidities in elderly patients with acute coronary syndromes" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "247" "paginaFinal" => "248" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Albert Ariza-Solé, Francesc Formiga, Eva Bernal, Alberto Garay" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Albert" "apellidos" => "Ariza-Solé" "email" => array:1 [ 0 => "aariza@bellvitgehospital.cat" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Francesc" "apellidos" => "Formiga" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Eva" "apellidos" => "Bernal" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Alberto" "apellidos" => "Garay" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Coronary Care Unit, Heart Diseases Institute, Bellvitge University Hospital, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Geriatrics Unit, Internal Medicine Department, Bellvitge University Hospital, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Cardiology Department, Germans Trias i Pujol University Hospital, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Avaliação do risco hemorrágico e comorbilidades em doentes idosos com síndromes coronárias agudas" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We have read with great interest the article by Faustino et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> recently published in this journal. The incidence of acute coronary syndromes (ACS) in the elderly is increasing, and information on clinical management and risk stratification in these patients is scarce, since they are clearly under-represented in clinical trials. Faustino et al. reported that the CRUSADE bleeding risk score had a low ability (area under the receiver operating characteristic curve [AUC] 0.51) to predict major in-hospital bleeding in a series of 544 octogenarian patients with non-ST-elevation ACS, suggesting the need for new tools to predict major bleeding in this clinical scenario. In contrast, the authors found the GRACE score had good performance for predicting in-hospital mortality.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In our opinion, the most important limitation of this interesting work is the use of a different bleeding definition from that which formed the basis for the performance of the CRUSADE score. In the original paper by Subherwal et al.,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> the CRUSADE bleeding criteria were fulfilled in almost 10% of patients, of whom 44% had a hematocrit drop >12% and 68% were transfused with a baseline hematocrit higher than 28%. Faustino et al. used the GUSTO bleeding criteria, which are significantly different from the CRUSADE criteria. On the other hand, only 16 patients in Faustino et al.’s series had major in-hospital bleeding, which may weaken their findings. However, we agree with the authors that these data may suggest the CRUSADE score has poor predictive ability in the elderly.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We recently<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> studied a population of 2036 consecutive ACS patients, assessing the predictive ability of the main available bleeding risk scores (CRUSADE, Mehran and ACTION) in patients aged 75 years or older (n=369, 18.1%) compared to younger patients. We consistently observed that the ability of the three scores to predict in-hospital major bleeding (according to their own definitions) was lower in the elderly. We also assessed the ability of the GRACE score to predict in-hospital major bleeding as defined by the Bleeding Academic Research Consortium definition. Interestingly, the GRACE score showed a good predictive ability for major bleeding in the elderly (AUC 0.697), slightly lower than in younger patients (AUC 0.742). The GRACE score has also shown a good predictive ability for ischemic events in very elderly patients in other series.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In our opinion, and as stated by Faustino et al., most of these findings may be due to the effect of age-related variables such as frailty, disability and comorbidities, which are rarely assessed in patients with ACS and may significantly hinder bleeding risk stratification in this clinical scenario. In addition, bleeding risk scores were based on populations with low representation of elderly patients, with mean ages ranging from 62 to 67 years.</p><p id="par0025" class="elsevierStylePara elsevierViewall">However, we believe that the results from this paper are very interesting and highlight the importance of improving risk stratification in the elderly with ACS. This growing age subgroup has a high risk for both ischemic and bleeding complications. The routine assessment of age-related variables<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">5,6</span></a> will probably contribute to better risk stratification and clinical management of elderly patients with ACS in the future.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Non-ST-elevation acute coronary syndromes in octogenarians: applicability of the GRACE and CRUSADE scores" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "for the National Registry of Acute Coronary Syndromes. Portuguese Society of Cardiology" "etal" => false "autores" => array:3 [ 0 => "A. Faustino" 1 => "P. Mota" 2 => "J. Silva" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.repc.2014.01.025" "Revista" => array:6 [ "tituloSerie" => "Rev Port Cardiol" "fecha" => "2014" "volumen" => "33" "paginaInicial" => "617" "paginaFinal" => "627" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25312887" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0040" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Baseline risk of major bleeding in non-ST-segment-elevation myocardial infarction: the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines) bleeding score" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "S. Subherwal" 1 => "R.G. Bach" 2 => "A.Y. Chen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/CIRCULATIONAHA.108.828541" "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "2009" "volumen" => "119" "paginaInicial" => "1873" "paginaFinal" => "1882" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19332461" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0045" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Efficacy of bleeding risk scores in elderly patients with acute coronary syndromes" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A. Ariza-Solé" 1 => "F. Formiga" 2 => "V. Lorente" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.rec.2013.10.008" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Cardiol" "fecha" => "2014" "volumen" => "67" "paginaInicial" => "463" "paginaFinal" => "470" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24863595" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0050" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute coronary syndrome in nonagenarians: clinical evolution and validation of the main risk scores" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "S. Gómez-Talavera" 1 => "I. Núñez-Gil" 2 => "D. Vivas" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.regg.2013.05.002" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Geriatr Gerontol" "fecha" => "2014" "volumen" => "49" "paginaInicial" => "5" "paginaFinal" => "9" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24055094" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0055" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Impact of frailty and functional status on outcomes in elderly patients with ST-segment elevation myocardial infarction undergoing primary angioplasty: rationale and design of the IFFANIAM study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A. Ariza-Solé" 1 => "F. Formiga" 2 => "M.T. Vidán" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/clc.22182" "Revista" => array:6 [ "tituloSerie" => "Clin Cardiol" "fecha" => "2013" "volumen" => "36" "paginaInicial" => "565" "paginaFinal" => "569" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24114768" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0060" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Frailty and other geriatric conditions for risk stratification of older patients with acute coronary syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J. Sanchis" 1 => "C. Bonanad" 2 => "V. Ruiz" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ahj.2014.07.022" "Revista" => array:6 [ "tituloSerie" => "Am Heart J" "fecha" => "2014" "volumen" => "168" "paginaInicial" => "784" "paginaFinal" => "791" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25440808" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003500000004/v2_201703300127/S2174204916300101/v2_201703300127/en/main.assets" "Apartado" => array:4 [ "identificador" => "29282" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003500000004/v2_201703300127/S2174204916300101/v2_201703300127/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204916300101?idApp=UINPBA00004E" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 5 | 13 |
| 2024 October | 31 | 29 | 60 |
| 2024 September | 46 | 23 | 69 |
| 2024 August | 53 | 28 | 81 |
| 2024 July | 31 | 37 | 68 |
| 2024 June | 31 | 22 | 53 |
| 2024 May | 31 | 14 | 45 |
| 2024 April | 25 | 30 | 55 |
| 2024 March | 29 | 19 | 48 |
| 2024 February | 19 | 18 | 37 |
| 2024 January | 27 | 21 | 48 |
| 2023 December | 21 | 24 | 45 |
| 2023 November | 30 | 22 | 52 |
| 2023 October | 19 | 13 | 32 |
| 2023 September | 19 | 26 | 45 |
| 2023 August | 24 | 30 | 54 |
| 2023 July | 26 | 8 | 34 |
| 2023 June | 21 | 8 | 29 |
| 2023 May | 30 | 29 | 59 |
| 2023 April | 18 | 3 | 21 |
| 2023 March | 26 | 22 | 48 |
| 2023 February | 27 | 23 | 50 |
| 2023 January | 18 | 12 | 30 |
| 2022 December | 28 | 23 | 51 |
| 2022 November | 29 | 19 | 48 |
| 2022 October | 25 | 15 | 40 |
| 2022 September | 26 | 42 | 68 |
| 2022 August | 27 | 31 | 58 |
| 2022 July | 33 | 30 | 63 |
| 2022 June | 21 | 17 | 38 |
| 2022 May | 14 | 28 | 42 |
| 2022 April | 29 | 30 | 59 |
| 2022 March | 20 | 30 | 50 |
| 2022 February | 24 | 28 | 52 |
| 2022 January | 17 | 23 | 40 |
| 2021 December | 20 | 24 | 44 |
| 2021 November | 30 | 35 | 65 |
| 2021 October | 35 | 46 | 81 |
| 2021 September | 14 | 31 | 45 |
| 2021 August | 39 | 34 | 73 |
| 2021 July | 17 | 25 | 42 |
| 2021 June | 20 | 17 | 37 |
| 2021 May | 26 | 39 | 65 |
| 2021 April | 32 | 33 | 65 |
| 2021 March | 46 | 22 | 68 |
| 2021 February | 34 | 14 | 48 |
| 2021 January | 31 | 10 | 41 |
| 2020 December | 17 | 7 | 24 |
| 2020 November | 23 | 17 | 40 |
| 2020 October | 16 | 11 | 27 |
| 2020 September | 30 | 14 | 44 |
| 2020 August | 19 | 8 | 27 |
| 2020 July | 22 | 13 | 35 |
| 2020 June | 30 | 11 | 41 |
| 2020 May | 24 | 4 | 28 |
| 2020 April | 31 | 9 | 40 |
| 2020 March | 24 | 8 | 32 |
| 2020 February | 75 | 18 | 93 |
| 2020 January | 40 | 6 | 46 |
| 2019 December | 30 | 5 | 35 |
| 2019 November | 35 | 13 | 48 |
| 2019 October | 24 | 6 | 30 |
| 2019 September | 18 | 5 | 23 |
| 2019 August | 18 | 5 | 23 |
| 2019 July | 34 | 11 | 45 |
| 2019 June | 20 | 11 | 31 |
| 2019 May | 29 | 8 | 37 |
| 2019 April | 16 | 18 | 34 |
| 2019 March | 38 | 8 | 46 |
| 2019 February | 50 | 9 | 59 |
| 2019 January | 29 | 7 | 36 |
| 2018 December | 31 | 11 | 42 |
| 2018 November | 38 | 9 | 47 |
| 2018 October | 86 | 11 | 97 |
| 2018 September | 29 | 12 | 41 |
| 2018 August | 23 | 7 | 30 |
| 2018 July | 25 | 5 | 30 |
| 2018 June | 22 | 2 | 24 |
| 2018 May | 40 | 6 | 46 |
| 2018 April | 50 | 6 | 56 |
| 2018 March | 28 | 11 | 39 |
| 2018 February | 36 | 3 | 39 |
| 2018 January | 39 | 7 | 46 |
| 2017 December | 59 | 7 | 66 |
| 2017 November | 23 | 13 | 36 |
| 2017 October | 21 | 8 | 29 |
| 2017 September | 18 | 8 | 26 |
| 2017 August | 20 | 11 | 31 |
| 2017 July | 25 | 17 | 42 |
| 2017 June | 36 | 18 | 54 |
| 2017 May | 33 | 10 | 43 |
| 2017 April | 30 | 4 | 34 |
| 2017 March | 26 | 47 | 73 |
| 2017 February | 21 | 4 | 25 |
| 2017 January | 22 | 10 | 32 |
| 2016 December | 24 | 7 | 31 |
| 2016 November | 27 | 8 | 35 |
| 2016 October | 34 | 6 | 40 |
| 2016 September | 25 | 11 | 36 |
| 2016 August | 10 | 1 | 11 |
| 2016 July | 12 | 9 | 21 |
| 2016 June | 14 | 15 | 29 |
| 2016 May | 19 | 26 | 45 |
| 2016 April | 5 | 7 | 12 |
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