RIETE Score for Risk of Hemorrhage in Pulmonary Embolism Treatment

Consider using the RIETE score to stratify patients’ risk for bleeding after anti-coagulation for DVT/PE in conjunction with situation specific risks/benefits.

The RIETE registry developed a clinical score to stratify a patient’s risk of major bleeding with anticoagulation for DVT or PE.

• Included all patients with symptomatic acute DVT or PE diagnosed by CTV or US for DVT and pulmonary angiography, lung scintigraphy or helical CT for PE
• Scoring system consisted of 6 criteria, 1 of which was worth 2 points, 2 worth 1.5 points each, and 3 worth 1 point each
• The study used 0 points to define low risk for major bleeding events (0.1% risk of bleeding), 1-4 points for intermediate risk (2.8% risk), and >4 points for high risk (6.2% risk)
• Major bleeding was defined as overt bleeding plus one of the following:
  • Required transfusion of 2+ units of blood,
  • Retroperitoneal, spinal or intracranial, OR
  • Fatal

Points to keep in mind:

• Study used same population for derivation and validation cohorts
• Did not distinguish between different types of anticoagulation
• Anemia was never defined
• Score has not been externally validated. The only validation study to date utilized the same RIETE database and used a different endpoint.

A subsequent risk score has been developed by the ATRIA group which also used similar criteria in their score to determine risk of bleeding after anti-coagulation with warfarin for atrial fibrillation. They also had a similar overall bleeding rate as the RIETE group.

The RIETE score is based on a very large cohort of patients and, if validated, has a significant difference in outcomes between the low and high risk groups, making it a potentially powerful tool to guide the decision to anticoagulate.