Novel Approach of Antithrombotic Potency Amongst Patients Admitted to Hospital with Bleeding Using HEMORR2HAGES Score: A Retrospective Cohort Study
Background: The purpose of this study was to evaluate whether a relationship exists between baseline
HEMORR2HAGES score and antithrombotic potency amongst patients presenting with bleeding complication. We hypothesized that the more antithrombotic regimen potency, the less HEMORR2HAGES score you have.
Methods: This is a retrospective observational study of patients admitted with a diagnosis of active bleeding between November 1, 2013 and August 31, 2015. The antithrombotic groups included patients on the following regimens: single antiplatelet therapy (SAP), single oral anticoagulant therapy (SOAC), dual antiplatelet therapy (DAPT), dual combination (SOAC+SAP), and triple antithrombotic therapy. The primary outcome was to review the mean HEMORR2HAGES score among the various groups.
Results: There were a total of 180 patients in the study. No significant difference was noted among the five groups in the HEMORR2HAGES score (P = .36). The highest
HEMORR2HAGES score was in the SAP group (3.23 ± 1.1). The lowest HEMORR2HAGES score was in the DAPT group (2.59 ± 1.2). In the Sub Group analysis, we compared single versus dual versus triple therapy, and we found the lowest HEMORR2HAGES score in the triple therapy group (2.70 ± 1.6); (P = .29).
Conclusions: Among patients admitted with active bleeding, the HEMORR2HAGES score did not differentiate antithrombotic potency amongst groups with various regimens. This study highlights the necessity to evaluate antithrombotic therapy according to benefits and harms.
Andrade JG, Deyell MW, Khoo C, et al. 2013. Risk of bleeding on triple antithrombotic therapy after percutaneous coronary intervention/stenting: a systematic review and meta-analysis. Can J Cardiol 29:204e212.
Apostolakis S, Lane DA, Guo Y, et al. 2012. Performance of the HEMORR2HAGES, ATRIA, and HAS-BLED bleeding risk-prediction scores in patients with atrial fibrillation undergoing anticoagulation: the AMADEUS (evaluating the use of SR34006 compared to warfarin or acenocoumarol in patients with atrial fibrillation) study. J Am Coll Cardiol 60:861–7.
D’Ascenzo F, Bollati M, Clementi F, et al. 2013. Incidence and predictors of coronary stent thrombosis: evidence from an international collaborative meta-analysis including 30 studies, 221,066 patients, and 4276 thromboses. Int J Cardiol 167:575e584.
Fang MC, Go AS, Chang Y, et al. 2011. A new risk scheme to predict warfarin-associated hemorrhage: the ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) study. J Am Coll Cardiol 58: 395– 401.
Gage BF, Yan Y, Milligan PE, et al. 2006. Clinical classification for predicting hemorrhages: results from the National Registry of Atrial Fibrillation (NRAF). Am Heart J. 151:713-9.
Hansen ML, Sorensen R, Clausen MT, et al. 2010. Risk of bleeding with single, dual, or triple therapy with warfarin, aspirin, and clopidogrel in patients with atrial fibrillation. Arch Intern Med 170:1433.
January CT, Wann LS, Calkins H, et al. 2019. AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: A report of the American college of cardiology/American heart association task force on clinical practice guidelines and the heart rhythm society. Heart Rhythm Jan 28. pii: S1547-5271(19)30037-2.
Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, Nelson ME, Wells PS, Gould MK, Dentali F, Crowther M, Kahn SR. 2012. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 141:e419S–e494S.
Klolk FA, Niemann C, Dellas C, et al. 2016. Performance of five different bleeding-prediction scores in patients with acute pulmonary embolism. J Thromb Thrombolysis 2:312-20.
Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitz- Maurice D, Galie N, Gibbs JS, Huisman MV, Humbert M, Kucher N, Lang I, Lankeit M, Lekakis J, Maack C, Mayer E, Meneveau N, Perrier A, Pruszczyk P, Rasmussen LH, Schindler TH, Svitil P, Vonk NA, Zamorano JL, Zompatori M. 2014. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism: the task force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC) Endorsed by the European Respiratory Society (ERS). Eur Heart J 35:3033–3069.
Lamberts M, Olesen JB, Ruwald MH, et al. 2012. Bleeding after initiation of multiple antithrombotic drugs, including triple therapy, in atrial fibrillation patients following myocardial infarction and coronary interventions: a nationwide cohort study. Circulation 126:1185-1193.
Orford JL, Fasseas P, Melby S, et al. 2004. Safety and efficacy of aspirin, clopidogrel, and warfarin after coronary stent placement in patients with an indication for anti- coagulation. Am Heart J 147:463e467.
Pisters R, Lane DA, Nieuwlaat R, et al. 2010. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest 138:1093–100.
Rubboli A, Halperin JL, Airaksinen KE, et al. 2008. Antithrombotic therapy in patients treated with oral anticoagulation undergoing coronary artery stenting. An expexrt consensus document with focus on atrial fibrillation. Ann Med 40:428.
Sorensen R, Hansen ML, Abildstrom SZ, et al. 2009. Risk of bleeding in patients with acute myocardial infarction treated with different combinations of aspirin, clopidogrel, and vitamin K antagonists in Denmark: a retrospective analysis of nationwide registry data. Lancet 374:1967.
Zalesak M, Siu K, Francis K, et al. 2013. Higher persistence in newly diagnosed nonvalvular atrial fibrillation patients treated with dabigatran versus warfarin. Circ Cardiovasc Qual Outcomes 5:567-74.
Zhao HJ, Zheng ZT, Wang ZH, et al. 2011. “Triple therapy” rather than “triple threat”: a meta-analysis of the two antithrombotic regimens after stent implantation in patients receiving long-term oral anticoagulant treatment. Chest 139:260e270.
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