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: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. 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Vivas" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.regg.2013.05.002" "Revista" => array:7 [ "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" ] ] "itemHostRev" => array:3 [ "pii" => "S0302283813006660" "estado" => "S300" "issn" => "03022838" ] ] ] ] ] ] ] 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:7 [ "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" ] ] "itemHostRev" => array:3 [ "pii" => "S0302283812006872" "estado" => "S300" "issn" => "03022838" ] ] ] ] ] ] ] 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" => "/08702551/0000003500000004/v1_201604010041/S0870255116000743/v1_201604010041/en/main.assets" "Apartado" => array:4 [ "identificador" => "29267" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Cartas ao Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/08702551/0000003500000004/v1_201604010041/S0870255116000743/v1_201604010041/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255116000743?idApp=UINPBA00004E" ]
| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 7 | 6 | 13 |
| 2024 Outubro | 35 | 31 | 66 |
| 2024 Setembro | 51 | 24 | 75 |
| 2024 Agosto | 49 | 28 | 77 |
| 2024 Julho | 40 | 29 | 69 |
| 2024 Junho | 35 | 24 | 59 |
| 2024 Maio | 31 | 17 | 48 |
| 2024 Abril | 41 | 28 | 69 |
| 2024 Maro | 33 | 23 | 56 |
| 2024 Fevereiro | 31 | 18 | 49 |
| 2024 Janeiro | 29 | 23 | 52 |
| 2023 Dezembro | 31 | 24 | 55 |
| 2023 Novembro | 30 | 33 | 63 |
| 2023 Outubro | 21 | 12 | 33 |
| 2023 Setembro | 24 | 20 | 44 |
| 2023 Agosto | 32 | 19 | 51 |
| 2023 Julho | 22 | 14 | 36 |
| 2023 Junho | 33 | 15 | 48 |
| 2023 Maio | 33 | 25 | 58 |
| 2023 Abril | 17 | 4 | 21 |
| 2023 Maro | 36 | 20 | 56 |
| 2023 Fevereiro | 26 | 24 | 50 |
| 2023 Janeiro | 17 | 20 | 37 |
| 2022 Dezembro | 31 | 18 | 49 |
| 2022 Novembro | 32 | 24 | 56 |
| 2022 Outubro | 26 | 21 | 47 |
| 2022 Setembro | 31 | 28 | 59 |
| 2022 Agosto | 25 | 27 | 52 |
| 2022 Julho | 36 | 34 | 70 |
| 2022 Junho | 17 | 28 | 45 |
| 2022 Maio | 21 | 32 | 53 |
| 2022 Abril | 30 | 34 | 64 |
| 2022 Maro | 30 | 33 | 63 |
| 2022 Fevereiro | 28 | 32 | 60 |
| 2022 Janeiro | 20 | 23 | 43 |
| 2021 Dezembro | 20 | 27 | 47 |
| 2021 Novembro | 29 | 32 | 61 |
| 2021 Outubro | 31 | 44 | 75 |
| 2021 Setembro | 28 | 32 | 60 |
| 2021 Agosto | 27 | 23 | 50 |
| 2021 Julho | 25 | 23 | 48 |
| 2021 Junho | 21 | 23 | 44 |
| 2021 Maio | 24 | 22 | 46 |
| 2021 Abril | 26 | 13 | 39 |
| 2021 Maro | 70 | 27 | 97 |
| 2021 Fevereiro | 43 | 12 | 55 |
| 2021 Janeiro | 27 | 13 | 40 |
| 2020 Dezembro | 34 | 3 | 37 |
| 2020 Novembro | 26 | 15 | 41 |
| 2020 Outubro | 27 | 12 | 39 |
| 2020 Setembro | 57 | 30 | 87 |
| 2020 Agosto | 19 | 10 | 29 |
| 2020 Julho | 31 | 9 | 40 |
| 2020 Junho | 39 | 6 | 45 |
| 2020 Maio | 38 | 5 | 43 |
| 2020 Abril | 37 | 7 | 44 |
| 2020 Maro | 35 | 10 | 45 |
| 2020 Fevereiro | 49 | 45 | 94 |
| 2020 Janeiro | 37 | 4 | 41 |
| 2019 Dezembro | 20 | 9 | 29 |
| 2019 Novembro | 29 | 4 | 33 |
| 2019 Outubro | 32 | 4 | 36 |
| 2019 Setembro | 16 | 5 | 21 |
| 2019 Agosto | 25 | 5 | 30 |
| 2019 Julho | 47 | 7 | 54 |
| 2019 Junho | 19 | 7 | 26 |
| 2019 Maio | 37 | 7 | 44 |
| 2019 Abril | 22 | 13 | 35 |
| 2019 Maro | 82 | 7 | 89 |
| 2019 Fevereiro | 63 | 16 | 79 |
| 2019 Janeiro | 47 | 4 | 51 |
| 2018 Dezembro | 32 | 10 | 42 |
| 2018 Novembro | 34 | 7 | 41 |
| 2018 Outubro | 110 | 28 | 138 |
| 2018 Setembro | 20 | 12 | 32 |
| 2018 Agosto | 26 | 13 | 39 |
| 2018 Julho | 21 | 9 | 30 |
| 2018 Junho | 29 | 4 | 33 |
| 2018 Maio | 42 | 7 | 49 |
| 2018 Abril | 45 | 2 | 47 |
| 2018 Maro | 76 | 7 | 83 |
| 2018 Fevereiro | 31 | 4 | 35 |
| 2018 Janeiro | 28 | 6 | 34 |
| 2017 Dezembro | 46 | 12 | 58 |
| 2017 Novembro | 28 | 13 | 41 |
| 2017 Outubro | 23 | 6 | 29 |
| 2017 Setembro | 27 | 11 | 38 |
| 2017 Agosto | 22 | 9 | 31 |
| 2017 Julho | 15 | 8 | 23 |
| 2017 Junho | 34 | 6 | 40 |
| 2017 Maio | 36 | 7 | 43 |
| 2017 Abril | 11 | 5 | 16 |
| 2017 Maro | 28 | 17 | 45 |
| 2017 Fevereiro | 23 | 2 | 25 |
| 2017 Janeiro | 21 | 3 | 24 |
| 2016 Dezembro | 30 | 5 | 35 |
| 2016 Novembro | 27 | 6 | 33 |
| 2016 Outubro | 24 | 5 | 29 |
| 2016 Setembro | 34 | 8 | 42 |
| 2016 Agosto | 16 | 9 | 25 |
| 2016 Julho | 17 | 10 | 27 |
| 2016 Junho | 5 | 11 | 16 |
| 2016 Maio | 1 | 0 | 1 |
| 2016 Abril | 114 | 34 | 148 |
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