Bleeding risk in patients hospitalized for non-ST-segment

elevation acute coronary syndromes in Switzerland:

performance of the CRUSADE score
Florian A Wenzl, Simon Kraler, Lorenz Räber, Barbara E Staehli, Marco Roffi, Olivier Muller, Nicolas Rodondi, Giovanni
G. Camici, Milo A. Puhan, Hans Rickli, Dragana Radovanovic, and Thomas F Lüscher

Florian A Wenzl, MD
August 29, 2022
Background & Aim
• Assessment of bleeding risk is important in patients with NSTE-ACS
• The CRUSADE score is the most established tool to estimate
bleeding risk
• The performance of CRUSADE in current patients is unclear
• Aim: To investigate the performance of the CRUSADE score in
contemporary European patients
Methods
• CRUSADE score in consecutive patients with NSTE-ACS
• ACS cohorts: SPUM-ACS (n=4 787), validation in AMIS Plus (n=46 939)
• Major bleeding in hospital defined as BARC class IIIB, IIIC, IV, or V
• External event adjudication in SPUM-ACS
• Discrimination evaluated by the AUC
• Calibration assessed by calibration plots and E:O ratios
• Clinical utility studied by decision curve analyses
• Multivariable-adjusted risk ratios for each score variable
 Poor discriminatory performance of CRUSADE
• Poor discriminatory performance:
AUC 0.65, 95% CI 0.57 to 0.72
• Poor calibration and overestimation
of bleeding risk across all risk
categories
• Low balanced accuracy: BA 0.50
• Decision curve analyses suggest
little to no net benefit
Predictors of major in-hospital bleeding
Adjusted for other score variables:

• Signs of heart failure

• Low hematocrit

• Low systolic blood pressure

Machine learning predictions provide better calibration
• PRAISE score† estimates 1-year post-discharge bleeding risk
• Adaptive boosting algorithm
• Better calibration for predicting in-hospital and post-discharge bleeding

†D'Ascenzo F et al. Lancet 2021.

Conclusion

• The CRUSADE score markedly overestimates bleeding risk in NSTE-ACS

• Use of the CRUSADE score provides little to no net clinical benefit
• Signs of heart failure, low hematocrit, and low systolic blood pressure
are strong predictors of major in-hospital bleeds

• Machine learning-based predictions outperform CRUSADE