CRUSADE Score for Post-MI Bleeding Risk
Antithrombotic agents are a critical part of treatment in patients with NSTEMI and STEMI, but major bleeding events are associated with worse outcomes in patients with ACS. The CRUSADE score was developed to stratify baseline risk of major bleeding in community-treated NSTEMI patients to facilitate optimal treatment selection. A subsequent study also validated the score in patients with STEMI as well.
- Included patients in a database of high-risk patients with non-ST elevation acute coronary syndrome in US hospitals from November 2001 through December 2006, totaling 89,134 patients from 485 sites.
- Excluded patients with unstable angina, those taking warfarin at home, died within 48 hours of hospital arrival, and those transferred out of a CRUSADE hospital.
- Population randomly divided into derivation cohort with 80% of the patients and a validation cohort with 20%.
- Based on derivation cohort, devised scoring system consisting of 8 criteria with varying point values.
- Study defined very low risk (3.1% risk of major bleeding) as bleeding score ≤20, low risk (5.5%) 21-30, moderate risk (8.5%) 31-40, high risk (11.9%) 41-50, and very high risk (19.5%) >50.
- Defined major bleeding as intracranial hemorrhage, retroperitoneal bleed, hematocrit drop ≥12%, any RBC transfusion when baseline hematocrit ≥28%, or any RBC transfusion when baseline hematocrit <28% with witnessed bleed.
- Risk score performed similarly well on the validation cohort.
- Recommend that patients with higher propensity for bleeding can prompt clinicians to make judicious treatment selections (conservative vs invasive approaches) and carefully dose antithrombotic medications.
Points to keep in mind:
- Original study used same population for derivation and validation cohorts.
- However, a smaller (782 patients) Spanish study applied the CRUSADE risk score to an entirely different population of NSTEMI patients and found it to be generally validated aside from a small subgroup of 48 patients who received ≥2 antithrombotic drugs but did not undergo cardiac catheterization.
- An additional study comparing the performance of the ACTION, CRUSADE and Mehran et al bleeding risk scores in predicting major bleeding events in patients with both NSTEMI and STEMI (despite the fact that CRUSADE was originally developed for NSTEMI patients) found that the CRUSADE score was the most accurate of the three in patients undergoing coronary arteriography.
- The CRUSADE bleeding risk score was subsequently validated in STEMI patients undergoing primary PCI though overall bleeding risk was lower in this population.
- CRUSADE was then compared to the ACUITY-HORIZONS and ACTION bleeding risk scores in a population of STEMI patients undergoing primary PCI showed that CRUSADE performed similarly to the ACTION risk score, but was superior to HORIZONS.
CRUSADE stratifies baseline risk of major bleeding in community-treated NSTEMI patients to facilitate optimal treatment selection.
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- Risks and benefits of anti-thrombotic therapy and invasive treatment should be carefully considered in ALL patients presenting with NSTEMI or STEMI.
- The CRUSADE bleeding risk score may have decreased utility in NSTEMI patients who receive 2 or more anti-thrombotic agents but do not undergo PCI.
- Alternative bleeding risk scores may also be utilized in certain groups of patients.
- Consider less invasive or high-risk anti-thrombotic dosage protocols in those STEMI/NSTEMI patients with increased risk for bleeding based on the CRUSADE bleeding risk score.