This Article Full Text Full Text (PDF) CME: Take the course for this article: Circulation: April 14, 2009, Volume 119, Number 14 All Versions of this Article: 119/14/1873    most recent CIRCULATIONAHA.108.828541v1 Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Subherwal, S. Articles by Alexander, K. P. Search for Related Content PubMed PubMed Citation Articles by Subherwal, S. Articles by Alexander, K. P. Pubmed/NCBI databases Compound via MeSH Substance via MeSH Medline Plus Health Information Heart Attack Related Collections Other Treatment Acute myocardial infarction Related Article

(Circulation. 2009;119:1873-1882.)
© 2009 American Heart Association, Inc.

Coronary Heart Disease

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

Sumeet Subherwal, MD; Richard G. Bach, MD; Anita Y. Chen, MS; Brian F. Gage, MD, MSc; Sunil V. Rao, MD; L. Kristin Newby, MD, MHS; Tracy Y. Wang, MD, MS; W. Brian Gibler, MD; E. Magnus Ohman, MD; Matthew T. Roe, MD, MHS; Charles V. Pollack, Jr, MD, MA; Eric D. Peterson, MD, MPH; Karen P. Alexander, MD

From the Washington University School of Medicine (S.S., R.G.B., B.F.G.), St Louis, Mo; Duke Clinical Research Institute (A.Y.C., S.V.R., L.K.N., T.Y.W., E.M.O., M.T.R., E.D.P., K.P.A.), Durham, NC; University of Cincinnati (W.B.G.), Cincinnati, Ohio; and Pennsylvania Hospital (C.V.P.), Philadelphia, Pa.

Correspondence to Richard G. Bach, MD, Cardiovascular Division, Washington University School of Medicine, Campus Box 8086, 660 S Euclid Ave, St Louis, MO 63110. E-mail rbach{at}im.wustl.edu

Received October 13, 2008; accepted January 28, 2009.

Background— Treatments for non–ST-segment–elevation myocardial infarction (NSTEMI) reduce ischemic events but increase bleeding. Baseline prediction of bleeding risk can complement ischemic risk prediction for optimization of NSTEMI care; however, existing models are not well suited for this purpose.

Methods and Results— We developed (n=71 277) and validated (n=17 857) a model that identifies 8 independent baseline predictors of in-hospital major bleeding among community-treated NSTEMI patients enrolled in the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE) Quality Improvement Initiative. Model performance was tested by c statistics in the derivation and validation cohorts and according to postadmission treatment (ie, invasive and antithrombotic therapy). The CRUSADE bleeding score (range 1 to 100 points) was created by assignment of weighted integers that corresponded to the coefficient of each variable. The rate of major bleeding increased by bleeding risk score quintiles: 3.1% for those at very low risk (score 20); 5.5% for those at low risk (score 21–30); 8.6% for those at moderate risk (score 31–40); 11.9% for those at high risk (score 41–50); and 19.5% for those at very high risk (score >50; P_trend <0.001). The c statistics for the major bleeding model (derivation=0.72 and validation=0.71) and risk score (derivation=0.71 and validation=0.70) were similar. The c statistics for the model among treatment subgroups were as follows: 2 antithrombotics=0.72; <2 antithrombotics=0.73; invasive approach=0.73; conservative approach=0.68.

Conclusions— The CRUSADE bleeding score quantifies risk for in-hospital major bleeding across all postadmission treatments, which enhances baseline risk assessment for NSTEMI care.

---

 

CLINICAL PERSPECTIVE

Related Article:

Clinical Summaries
Circulation 2009 119: 1843-1845. [Extract] [Full Text]

This article has been cited by other articles:

				R. P. Giugliano and E. Braunwald The Year in Non-ST-Segment Elevation Acute Coronary Syndrome. J. Am. Coll. Cardiol., October 13, 2009; 54(16): 1544 - 1555. [Full Text] [PDF]

				Estimating Bleeding Risk in Patients with Non-ST-Segment-Elevation MI Journal Watch Cardiology, May 6, 2009; 2009(506): 2 - 2. [Full Text]

				J. L. Anderson Stopping the Hemorrhage: A New Baseline Bleeding Score Brings Us a Step Closer for Patients With Non-ST-Elevation Myocardial Infarction Circulation, April 14, 2009; 119(14): 1846 - 1849. [Full Text] [PDF]