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    "titulo" => "The CRUSADE score and bleeding in acute coronary syndrome"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The spectrum of patients admitted to hospital with acute coronary syndrome &#40;ACS&#41; is very wide&#44; from simple to complex patients&#44; with different diseases&#46; Therapeutic measures intended to reduce ischemic events&#44; by antithrombotic and coronary interventions&#44; also have the effect of increasing risk for bleeding complications&#46; These two elements need to be balanced at admission&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The European and American guidelines recommend use of the Global Registry for Acute Coronary Events &#40;GRACE&#41; or the Thrombolysis in Myocardial Infarction &#40;TIMI&#41; risk scores for ischemic events and the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC&#47;AHA guidelines &#40;CRUSADE&#41; score for bleeding events&#46;<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&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> although not its severity&#44; for which coronary angiography is required&#46; Assessment of coronary anatomy is an invasive procedure that increases bleeding risk but enables optimization of therapeutic strategy&#46; In the Portuguese Registry on Acute Coronary Syndromes &#40;ProACS&#41; the adoption of an invasive strategy&#44; particularly within 24 hours&#44; was accompanied by reductions in in-hospital mortality&#46;<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&#44; 2003&#44; through December 31&#44; 2006&#46; Given subsequent developments in medical therapy and interventions&#44; the question is whether CRUSADE is still a good score to predict bleeding in ACS&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The article by Bento et al&#46;<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&#46; They performed a single-center retrospective study of 2818 patients admitted with ACS between 2010 and 2014&#46; The CRUSADE score was calculated for each patient&#44; and its discrimination and goodness of fit were assessed by the area under the receiver operating characteristic curve &#40;AUC&#41; and by the Hosmer-Lemeshow test&#44; respectively&#46; Predictors of in-hospital major bleeding were determined&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The incidence of major bleeding in the different categories of the CRUSADE score was 0&#46;5&#37; in the very low risk category &#40;rate estimated by the score 3&#46;1&#37;&#41;&#44; 1&#46;5&#37; in the low risk category &#40;5&#46;5&#37;&#41;&#44; 1&#46;6&#37; in the moderate risk category &#40;8&#46;6&#37;&#41;&#44; 5&#46;5&#37; in the high risk category &#40;11&#46;9&#37;&#41;&#44; and 4&#46;4&#37; in the very high risk category &#40;19&#46;5&#37;&#41;&#46; The predictive ability of the CRUSADE score for major bleeding was only moderate &#40;AUC 0&#46;73&#41; and although it presented some discriminatory power&#44; it significantly overestimated the major bleeding rate&#44; especially in patients at higher risk&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In multivariate analysis&#44; advanced age&#44; femoral vascular access&#44; higher heart rate on admission and use of ticagrelor during hospital stay were predictors of major bleeding&#44; which was associated with higher in-hospital mortality &#40;15&#46;4&#37; vs&#46; 3&#46;8&#37;&#44; p&#60;0&#46;001&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In this study&#44; 91&#46;5&#37; of patients underwent coronary angiography by radial access&#46; Less than 2&#37; of such procedures were performed via a radial approach in the USA in 2007&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> which is one reason there was less major bleeding in Bento et al&#46; than in the CRUSADE cohort&#44; since transradial PCI is associated with lower vascular and bleeding complication rates&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The OASIS-5 trial&#44; published in 2006&#44; demonstrated that fondaparinux is similar to enoxaparin in reducing the risk of ischemic events at nine days&#44; but substantially reduces major bleeding and long-term mortality and morbidity&#46;<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&#44; while in Bento et al&#46; it was used for anticoagulation in 48&#37; of patients&#44; which is another reason for their lower bleeding rates&#46;</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&#44; which may also have contributed to the low rate of major bleeding&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The definition of major bleeding in CRUSADE is different from that of GUSTO&#44; which may be a limitation of this study&#44; but this does not explain the large difference between bleeding events predicted by the CRUSADE score and those actually observed in the study&#46;</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&#44; and a new score is needed for bleeding risk stratification in ACS&#46;</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&#46;</p></span></span>"
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