Bleeding risk stratification in an era of aggressive management of acute coronary syndromes

Table 1 Bleeding definitions

Trial	Definition
TIMI	Major bleeding: Intracranial hemorrhage or decrease of 5 g/dL in hemoglobin or 15% in hematocrit
	Minor bleeding: Decrease of 3 g/dL in hemoglobin with known source of blood los sor decrease of 4 g/dL in hemoglobin withoun known source of blood loss
GUSTO	Major bleeding: Fatal, intracranial, Retroperitoneal, intraocular leading to visión loss, or transfusion of 2 U
	Minor bleeding: any clinically significant bleeding not meeting major criteria leading to study drug interruption, surgery, or transfusion of 1 U of blood
ACUITY	Major bleeding: Intracranial or intraocular bleeding, hemorrhage at access site requiring intervention, hematoma ≥ 5 cm, decrease ≥ 4 g/dL of hemoglobin without overt bleeding source or ≥ 3 g/dL with source, reoperation for bleeding, or transfusion of blood product
	Minor bleeding: any clinically significant bleeding not meeting major criteria
CRUSADE	Major bleeding: intracranial hemorrhage, documented retroperitoneal bleed, hematocrit drop ≥ 12% (baseline to nadir), any red blood cell transfusion when baseline hematocrit was ≥ 28%, or any red blood cell transfusion when baseline hematocrit was < 28% with witnessed bleed
	Minor bleeding: any clinically significant bleeding not meeting major criteria
GRACE	Major bleeding: Life-threatening bleeding requiring transfusion of ≥ 2 U of packed red blood cells, bleeding resulting in absolute hematocrit decrease ≥ 10% or death hemorrhagic/subdural hematoma
	Minor bleeding: any clinically significant bleeding not meeting major criteria
BARC	Type 0: No bleeding
	Type 1: Bleeding that is not actionable and does not cause the patient to seek unscheduled performance of studies, hospitalization, or treatment by a health care professional; may include episodes leading to self-discontinuation of medical therapy by the patient without consulting a health care professional
	Type 2: Any overt, actionable sign of bleeding (e.g., more bleeding than would be expected for a clinical circumstance, including bleeding found by imaging alone) that does not fit the criteria for type 3, 4, or 5 but does meet at least one of the following criteria: requiring nonsurgical, medical intervention by a health care professional; leading to hospitalization or increased level of care; or prompting evaluation
	Type 3a: Overt bleeding plus hemoglobin drop of 3-5 g/dL (provided hemoglobin drop is related to bleed), or any transfusion with overt bleeding
	Type 3b: Overt bleeding plus hemoglobin drop ≥ 5 g/dL (provided hemoglobin drop is related to bleed), or cardiac tamponade, or bleeding requiring surgical intervention for control (excluding dental/nasal/skin/hemorrhoid), or bleeding requiring intravenous vasoactive agents
	Type 3c: Intracranial bleeding (does not include microbleeds or hemorrhagic transformation, does include intraspinal), or subcategories confirmed by autopsy or imaging or lumbar puncture, or intraocular bleed compromising vision
	Type 4: Coronary artery bypass graft-related bleeding, or perioperative intracranial bleeding within 48 h, or reoperation after closure of sternotomy for the purpose of controlling bleeding, or transfusion of ≥ 5 U whole blood or packed red blood cells within a 48-h period, or chest tube output ≥ 2 L within a 24-h period
	Type 5 or fatal bleeding A: Probable fatal bleeding; no autopsy or imaging confirmation but clinically suspicious
	Type 5 or fatal bleeding B: Definite fatal bleeding; overt bleeding or autopsy or imaging confirmation

ACUITY: Acute catheterization and urgent intervention triage strategy; CRUSADE: Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines; GRACE: Global Registry of Acute Coronary Events; BARC: Bleeding Academic Research Consortium.

Table 2 Bleeding risk scores

Bleeding risk scores	Action		Mehran et al		CRUSADE
variables	Values	Points	Values	Points	Values	Points
Sex	Male	0	Male	0	Male	0
	Female	4	Female	8	Female	8
Age (yr)	≤ 40	0	< 50	0
	41-50	1	50-59	3
	51-60	2	60-69	6
	61-70	3	70-79	9
	71-80	4	≥ 80	12
	81-90	5
	≥ 91	6
Weight (kg)	≤ 50	5
	51-70	4
	71-100	3
	101-120	2
	121-140	1
	≥ 141	0
Systolic blood pressure (mmHg)	≤ 90	4			≤ 90	10
	91-100	3			91-100	8
	101-120	2			101-120	5
	121-140	1			121-180	1
	141-170	0			181-200	3
	171-200	1			≥ 201	5
	≥ 201	2
Heart rate (BPM)	≤ 40	0			≤ 70	0
	41-60	2			71-80	1
	61-70	3			81-90	3
	71-80	5			91-100	6
	81-100	6			101-110	8
	101-110	8			111-120	10
	111-120	9			≥ 121	11
	121-130	11
	131-150	12
	≥ 151	14
Signs of heart failure	None	0			No	0
	Killip 2-3	3			Yes	7
	Cardiogenic shock	15
Diabetes mellitus	No	0			No	0
	Yes	3			Yes	6
Prior vascular disease	No	0			No	0
	Yes	3			Yes	6
Home warfarin use	No	0
	Yes	2
Antithrombotic medications			Heparin plus GPI	0
			Bivalirudin	-5
ECG changes	No ST changes	0	No ST elevation	0
	ST depresión	3	ST elevation	6
	ST transient elevation	7
	ST elevation
Troponine I			Normal	0
			Raised	6
Serum creatinine (mg/dL)	< 0.80	0	< 1.00	0
	0.80-1.59	1	1.00-1.19	2
	1.60-1.99	2	1.20-1.39	3
	2.00-2.99	4	1.40-1.59	5
	3.00-3.99	6	1.60-1.79	6
	4.00-4.99	8	1.80-1.99	8
	5.00-5.99	10	≥ 2.00	10
	≥ 6.00	11
	On dialysis	11
Creatinine clearance (mL/min)					≤ 15.0	39
					15.1-30.0	35
					30.1-60.0	28
					60.1-90.0	17
					90.1-120.0	7
					> 120	0
Baseline hemoglobin (g/dL)	< 5.0	17
	5.0-7.9	15
	8.0-9.9	13
	10.0-10.9	12
	11.0-13.9	9
	14.0-15.9	6
	≥ 16.0	2
Baseline hematocrit (%)					< 31.0	9
					31.0-33.9	7
					34.0-36.9	3
					37.0-39.9	2
					≥ 40.0	0
Anemia			No	0
			Yes	6
White blood cell count (giga/L)			< 10.0	0
			10.0-11.9	2
			12.0-13.9	3
			14.0-15.9	5
			16.0-17.9	6
			18.0-19.9	8
			≥ 20.0	10

CRUSADE: The Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines; GPI: Glycoprotein IIb/IIIa inhibitors; ECG: Electrocardiography; BPM: Beats per minute.