Editorial comment
The CRUSADE score and bleeding in acute coronary syndrome
Score CRUSADE e a hemorragia na Síndrome Coronária Aguda
Jorge Mimoso
Serviço de Cardiologia, Centro Hospitalar e Universitário do Algarve, Faro, Portugal
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Therapeutic measures intended to reduce ischemic events, by antithrombotic and coronary interventions, also have the effect of increasing risk for bleeding complications. These two elements need to be balanced at admission.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The European and American guidelines recommend use of the Global Registry for Acute Coronary Events (GRACE) or the Thrombolysis in Myocardial Infarction (TIMI) risk scores for ischemic events and the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE) score for bleeding events.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The TIMI and GRACE scores have been thoroughly validated for assessing prognosis in coronary artery disease,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> although not its severity, for which coronary angiography is required. Assessment of coronary anatomy is an invasive procedure that increases bleeding risk but enables optimization of therapeutic strategy. In the Portuguese Registry on Acute Coronary Syndromes (ProACS) the adoption of an invasive strategy, particularly within 24 hours, was accompanied by reductions in in-hospital mortality.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The CRUSADE bleeding score was developed from a database of patients enrolled from February 15, 2003, through December 31, 2006. Given subsequent developments in medical therapy and interventions, the question is whether CRUSADE is still a good score to predict bleeding in ACS.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The article by Bento et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> published in this issue of the <span class="elsevierStyleItalic">Journal</span> sets out to answer this question. They performed a single-center retrospective study of 2818 patients admitted with ACS between 2010 and 2014. The CRUSADE score was calculated for each patient, and its discrimination and goodness of fit were assessed by the area under the receiver operating characteristic curve (AUC) and by the Hosmer-Lemeshow test, respectively. Predictors of in-hospital major bleeding were determined.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The incidence of major bleeding in the different categories of the CRUSADE score was 0.5% in the very low risk category (rate estimated by the score 3.1%), 1.5% in the low risk category (5.5%), 1.6% in the moderate risk category (8.6%), 5.5% in the high risk category (11.9%), and 4.4% in the very high risk category (19.5%). The predictive ability of the CRUSADE score for major bleeding was only moderate (AUC 0.73) and although it presented some discriminatory power, it significantly overestimated the major bleeding rate, especially in patients at higher risk.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In multivariate analysis, advanced age, femoral vascular access, higher heart rate on admission and use of ticagrelor during hospital stay were predictors of major bleeding, which was associated with higher in-hospital mortality (15.4% vs. 3.8%, p<0.001).</p><p id="par0040" class="elsevierStylePara elsevierViewall">In this study, 91.5% of patients underwent coronary angiography by radial access. Less than 2% of such procedures were performed via a radial approach in the USA in 2007,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> which is one reason there was less major bleeding in Bento et al. than in the CRUSADE cohort, since transradial PCI is associated with lower vascular and bleeding complication rates.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The OASIS-5 trial, published in 2006, demonstrated that fondaparinux is similar to enoxaparin in reducing the risk of ischemic events at nine days, but substantially reduces major bleeding and long-term mortality and morbidity.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> Fondaparinux was used little in the years during which the CRUSADE score was being validated, while in Bento et al. it was used for anticoagulation in 48% of patients, which is another reason for their lower bleeding rates.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The authors note that their patients preferably received a P2Y<span class="elsevierStyleInf">12</span> receptor inhibitor during or after angioplasty, which may also have contributed to the low rate of major bleeding.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The definition of major bleeding in CRUSADE is different from that of GUSTO, which may be a limitation of this study, but this does not explain the large difference between bleeding events predicted by the CRUSADE score and those actually observed in the study.</p><p id="par0060" class="elsevierStylePara elsevierViewall">These results show that in current practice the CRUSADE score is no longer a good tool to predict bleeding events, and a new score is needed for bleeding risk stratification in ACS.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The author has 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" => "bibs0015" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "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. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 2 | 7 |
| 2024 October | 48 | 33 | 81 |
| 2024 September | 55 | 22 | 77 |
| 2024 August | 48 | 29 | 77 |
| 2024 July | 39 | 36 | 75 |
| 2024 June | 37 | 21 | 58 |
| 2024 May | 41 | 17 | 58 |
| 2024 April | 28 | 21 | 49 |
| 2024 March | 31 | 31 | 62 |
| 2024 February | 40 | 21 | 61 |
| 2024 January | 24 | 14 | 38 |
| 2023 December | 25 | 27 | 52 |
| 2023 November | 31 | 26 | 57 |
| 2023 October | 20 | 13 | 33 |
| 2023 September | 20 | 15 | 35 |
| 2023 August | 24 | 20 | 44 |
| 2023 July | 49 | 12 | 61 |
| 2023 June | 57 | 15 | 72 |
| 2023 May | 47 | 26 | 73 |
| 2023 April | 28 | 2 | 30 |
| 2023 March | 31 | 22 | 53 |
| 2023 February | 27 | 17 | 44 |
| 2023 January | 26 | 10 | 36 |
| 2022 December | 36 | 21 | 57 |
| 2022 November | 37 | 18 | 55 |
| 2022 October | 42 | 24 | 66 |
| 2022 September | 26 | 29 | 55 |
| 2022 August | 53 | 25 | 78 |
| 2022 July | 36 | 33 | 69 |
| 2022 June | 51 | 27 | 78 |
| 2022 May | 29 | 27 | 56 |
| 2022 April | 35 | 30 | 65 |
| 2022 March | 34 | 45 | 79 |
| 2022 February | 59 | 40 | 99 |
| 2022 January | 69 | 21 | 90 |
| 2021 December | 47 | 29 | 76 |
| 2021 November | 66 | 36 | 102 |
| 2021 October | 82 | 48 | 130 |
| 2021 September | 57 | 27 | 84 |
| 2021 August | 77 | 29 | 106 |
| 2021 July | 91 | 31 | 122 |
| 2021 June | 66 | 26 | 92 |
| 2021 May | 92 | 39 | 131 |
| 2021 April | 221 | 62 | 283 |
| 2021 March | 137 | 28 | 165 |
| 2021 February | 112 | 14 | 126 |
| 2021 January | 112 | 24 | 136 |
| 2020 December | 97 | 20 | 117 |
| 2020 November | 74 | 22 | 96 |
| 2020 October | 45 | 11 | 56 |
| 2020 September | 60 | 27 | 87 |
| 2020 August | 45 | 14 | 59 |
| 2020 July | 47 | 28 | 75 |
| 2020 June | 26 | 13 | 39 |
| 2020 May | 37 | 19 | 56 |
| 2020 April | 43 | 20 | 63 |
| 2020 March | 49 | 14 | 63 |
| 2020 February | 92 | 37 | 129 |
| 2020 January | 41 | 26 | 67 |
| 2019 December | 27 | 8 | 35 |
| 2019 November | 19 | 15 | 34 |
| 2019 October | 26 | 16 | 42 |
| 2019 September | 54 | 12 | 66 |
| 2019 August | 24 | 16 | 40 |
| 2019 July | 19 | 9 | 28 |
| 2019 June | 28 | 20 | 48 |
| 2019 May | 25 | 9 | 34 |
| 2019 April | 20 | 17 | 37 |
| 2019 March | 15 | 16 | 31 |
| 2019 February | 11 | 12 | 23 |
| 2019 January | 21 | 8 | 29 |
| 2018 December | 8 | 14 | 22 |
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