Landefeld C S, McGuire E, Rosenblatt M W
Division of General Internal Medicine, University Hospitals of Cleveland, Ohio 44106.
Am J Med. 1990 Nov;89(5):569-78. doi: 10.1016/0002-9343(90)90174-c.
To construct and test prospectively a bleeding risk index for estimating the probability of major bleeding in hospitalized patients starting long-term anticoagulant therapy.
In an inception cohort of 617 patients starting long-term anticoagulant therapy in one hospital, data were gathered retrospectively and bleeding was classified using reliable explicit criteria. We constructed a bleeding risk index by identifying and weighting independent predictors of major bleeding using a multivariate proportional-hazards model. The bleeding risk index was tested in 394 other patients prospectively identified in a second hospital. The index was compared to physicians' predictions.
Major bleeding developed before discharge in 61 of all 1,011 patients (6%). The bleeding risk index included four independent risk factors for major in-hospital bleeding: the number of specific comorbid conditions; heparin use in patients aged 60 years or older; maximal prothrombin or partial thromboplastin time 2.0 or more times control; liver dysfunction worsening during therapy. In the testing group, the index predicted major bleeding, which occurred in 3% of 235 low-risk patients, 16% of 96 middle-risk patients, and 19% of 63 high-risk patients (p less than 0.001). The bleeding risk index performed as well as physicians' predictions, and integration of the bleeding risk index with physicians' predictions led to a classification system that was more sensitive (p = 0.03) than physicians' predictions alone. In 86% of patients with a high risk of major bleeding, we identified specific ways of improving therapy, e.g., avoiding overanticoagulation and nonsteroidal anti-inflammatory agents.
The bleeding risk index provides valid estimates of the probability of major bleeding in hospitalized patients starting long-term anticoagulant therapy and complements physicians' predictions. The possibility that bleeding can be prevented in high-risk patients warrants prospective evaluation.
前瞻性构建并测试一个出血风险指数，用于评估开始长期抗凝治疗的住院患者发生大出血的概率。
在一家医院开始长期抗凝治疗的617例患者的初始队列中，回顾性收集数据，并使用可靠的明确标准对出血进行分类。我们使用多变量比例风险模型识别并权衡大出血的独立预测因素，构建了一个出血风险指数。该出血风险指数在另一家医院前瞻性确定的394例其他患者中进行了测试。将该指数与医生的预测进行比较。
在所有1011例患者中，61例（6%）在出院前发生大出血。出血风险指数包括住院期间大出血的四个独立风险因素：特定合并症的数量；60岁及以上患者使用肝素；凝血酶原或部分凝血活酶时间最大值为对照值的2.0倍或更多；治疗期间肝功能恶化。在测试组中，该指数预测了大出血情况，235例低风险患者中有3%发生大出血，96例中风险患者中有16%发生大出血，63例高风险患者中有19%发生大出血（p<0.001）。出血风险指数的表现与医生的预测相当，将出血风险指数与医生的预测相结合产生的分类系统比单独的医生预测更敏感（p = 0.03）。在86%大出血高风险的患者中，我们确定了改善治疗的具体方法，例如避免过度抗凝和非甾体类抗炎药。
出血风险指数可为开始长期抗凝治疗的住院患者发生大出血的概率提供有效的评估，并补充医生的预测。高风险患者出血可预防的可能性值得进行前瞻性评估。
