Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand; Department of Medicine, University of Auckland, Auckland, New Zealand.
Department of Cardiology, Royal Melbourne Hospital, Melbourne, Vic, Australia.
Heart Lung Circ. 2020 Dec;29(12):1749-1757. doi: 10.1016/j.hlc.2020.04.008. Epub 2020 Jun 9.
Bleeding is a common and frequently devastating complication in acute coronary syndrome (ACS). It is critical to evaluate in the current era of ACS management involving invasive strategies and potent anti-thrombotics. Risk models remain under-utilised in this setting but may guide the choice and duration of therapy. We compared their performances for predicting bleeding in ACS patients in this meta-analysis.
Medline, EMBASE, Cochrane and Scopus were searched for relevant articles from 1980 to 31 December 2017 assessing external validation of risk scores for bleeding after ACS. Two (2) authors independently reviewed the searched studies for eligibility, followed by pooled analyses using random effects models.
Amongst 1,843 articles searched, 73 full-texts were reviewed and 17 studies totalling 18,155 patients were included for analysis. C-statistics (95% confidence interval) for predicting in-hospital major bleeding by risk model were Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE) 0.714 (0.659-0.779), Acute Catheterization and Urgent Intervention Triage strategY (ACUITY) 0.711 (0.626-0.797), Acute Coronary Treatment and Intervention Outcomes Network (ACTION) 0.767 (0.737-0.797), Global Registry of Acute Coronary Events (GRACE) 0.689 (0.473-0.905) and HAS-BLED 0.636 (0.460-0.812). CRUSADE also predicted bleeding during medium-term follow-up c=0.704 (0.644-0.765). It performed better for radial versus femoral access (c=0.826 and 0.734), invasive versus non-invasive strategy (c=0.752 and 0.625) and similarly for ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI) (c=0.791 and 0.760). Heterogeneities of studies and paucity of studies assessing risk scores beyond CRUSADE were important limitations.
Acute coronary syndrome-specific bleeding scores had moderate discrimination for bleeding, while the GRACE and HAS-BLED scores could not. The ACTION score had the highest pooled c-statistic, while the CRUSADE score was the most widely studied, and also performed better for invasive strategy and radial access subgroups.
出血是急性冠脉综合征（ACS）的常见且常具破坏性的并发症。在涉及介入策略和强效抗血栓药物的 ACS 管理时代，评估出血风险至关重要。风险模型在这种情况下仍未得到充分利用，但可能有助于指导治疗的选择和持续时间。我们在这项荟萃分析中比较了它们在预测 ACS 患者出血方面的表现。
从 1980 年至 2017 年 12 月 31 日，我们在 Medline、EMBASE、Cochrane 和 Scopus 中检索了评估 ACS 后出血风险评分外部验证的相关文章。两名作者独立审查了检索到的研究的入选标准，然后使用随机效应模型进行汇总分析。
在搜索到的 1843 篇文章中，有 73 篇全文进行了回顾，共纳入 17 项研究，总计 18155 例患者进行了分析。风险模型预测住院期间大出血的 C 统计量（95%置信区间）为：快速不稳定型心绞痛患者风险分层以抑制不良结果并早期实施 ACC/AHA 指南（CRUSADE）0.714（0.659-0.779）、急性经皮冠状动脉介入治疗和紧急干预策略（ACUITY）0.711（0.626-0.797）、急性冠状动脉治疗和干预结局网络（ACTION）0.767（0.737-0.797）、全球急性冠脉事件登记处（GRACE）0.689（0.473-0.905）和 HAS-BLED 0.636（0.460-0.812）。CRUSADE 还预测了中期随访期间的出血，c=0.704（0.644-0.765）。与股动脉入路相比，桡动脉入路的预测效果更好（c=0.826 和 0.734），与非介入策略相比，介入策略的预测效果更好（c=0.752 和 0.625），ST 段抬高型心肌梗死（STEMI）和非 ST 段抬高型心肌梗死（NSTEMI）的预测效果也相似（c=0.791 和 0.760）。研究的异质性和缺乏对 CRUSADE 以外的风险评分的研究是重要的局限性。
急性冠脉综合征特异性出血评分对出血有中等程度的判别能力，而 GRACE 和 HAS-BLED 评分则没有。ACTION 评分的汇总 C 统计量最高，而 CRUSADE 评分的研究最多，在介入策略和桡动脉入路亚组中的表现也更好。
