The high-risk bleeding category of different scores in patients with venous thromboembolism: Systematic review and meta-analysis

  • Miguel Marques Antunes
    Affiliations
    Cardiovascular Center of the University of Lisbon (CCUL), Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, Lisbon 1649-028, Portugal

    Centro Hospitalar Universitário Lisboa Central, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal
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  • Mariana Alves
    Affiliations
    Serviço de Medicina III, Hospital Pulido Valente, CHULN, Lisbon, Portugal
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  • Fausto J. Pinto
    Affiliations
    Cardiovascular Center of the University of Lisbon (CCUL), Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, Lisbon 1649-028, Portugal

    Serviço de Cardiologia, Hospital Universitário de Santa Maria, CHULN, CAML, Av. Prof. Egas Moniz, Lisbon 1649-028, Portugal
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  • Giancarlo Agnelli
    Affiliations
    Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Perugia, Italy
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  • Daniel Caldeira
    Correspondence
    Corresponding author.
    Affiliations
    Cardiovascular Center of the University of Lisbon (CCUL), Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, Lisbon 1649-028, Portugal

    Serviço de Cardiologia, Hospital Universitário de Santa Maria, CHULN, CAML, Av. Prof. Egas Moniz, Lisbon 1649-028, Portugal

    Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa, Portugal; Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Portugal.
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Published:November 01, 2021DOI:https://doi.org/10.1016/j.ejim.2021.10.014

      Highlights

      • Risk/benefit weighting of anticoagulation in venous thromboembolism is needed.
      • Anticoagulation duration and regimens are influenced by the patient's bleeding risk.
      • Many risk scores are neither user-friendly nor updated to current clinical practice.
      • Most available scores have a modest sensitivity to identify the high-risk bleeders.
      • VTE-BLEED had the best overall performance among all scores.

      Abstract

      Background

      In patients with venous thromboembolism (VTE), bleeding risk should be carefully assessed but none of the available risk scores is currently recommended. The aim of this study was to systematically evaluate the performance of bleeding scores in patients with VTE focusing on high-risk patients.

      Methods

      Longitudinal studies were searched in Medline and Cochrane Library, as well as reviews and references of retrieved articles. Studies were identified, data were extracted, and reporting quality was evaluated. We determined the sensitivity, specificity, positive likelihood ratio (LR+), and diagnostic odds ratio (DOR) of the ‘high risk’ category of each bleeding score. Random effects meta-analysis was performed in order to derive the central estimates and 95% confidence intervals (95% CI).

      Results

      Twenty-one studies and ten bleeding scores fulfilled the inclusion criteria. VTE-BLEED showed the highest sensitivity but the second-lowest specificity (Se 76%; Sp 61%), followed by ACCP (Se 59%; Sp 57%). The remaining scores had high specificity (> 80%) but a low sensitivity (< 20%). HEMORR2HAGES and Niewenhuis score showed the best performance regarding LR+ that was 2.67 and 5.91, respectively. Regarding DOR, the Niewenhuis score and VTE-BLEED were the best performers with 9.04; 95% CI 3.87–21.09 and 4.94 95% CI 2.66–9.09, respectively. In a cohort with patients predominantly treated with direct oral anticoagulants (DOACs), VTE-BLEED had the highest sensitivity (Se 77%; Sp 60%).

      Conclusions

      Overall, the majority of the risk scores showed a moderate ability to forecast major bleeding events, with the VTE-BLEED as the most sensitive in patients treated with DOACs.

      Keywords

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