Published Online
on March 30, 2009

A more recent version of this article appeared on April 14, 2009

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Submitted on October 13, 2008
Accepted on January 28, 2009

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, and 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.

^* To whom correspondence should be addressed. E-mail: rbach{at}im.wustl.edu.

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.

Key words: myocardial infarction • bleeding • risk assessment

Related Article:

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

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