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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 30, No 4, July/August 2019
AFRICA
201
angiography with a CRUSADE score of
>
30 were under a
significantly increased risk of in-hospital bleeding compared to
those with a CRUSADE score
≤
30; however the HAS-BLED
score was more valuable for predicting in-hospital bleeding in
these patients compared to the CRUSADE score. To the best of
our knowledge, this is the first study to compare bleeding risk
scores in this patient group.
One of the most important causes of co-morbidity in
patients with stable coronary artery disease undergoing elective
coronary angiography is haemorrhage. For this reason, avoiding
bleeding is as important as treating ischaemia in the patient.
8
Since bleeding is a significant cause of morbidity and mortality
in these patients, a precision risk-analysis method is needed
to identify patients who are at high risk of bleeding after the
invasive coronary angiography procedure.
9
Many risk models have been used to predict this important
co-morbid situation. Rao
et al
. found that bleeding complications
in patients presenting with ACS increased long- and short-term
mortality rates, and suggested that the GUSTO bleeding risk
classification was successful in identifying short- and long-term
adverse cardiac event risk among this patient population. Hence,
they suggested that identifying patients with ACS with high
bleeding risk and using appropriate management techniques
could improve outcomes.
1
Although this study provides valuable
information, it provides information only on patients presenting
with ACS.
In another study, the SYNTAX score was shown to be
associated with major bleeding events in patients presenting
with NSTEMI who underwent PCI.
10
It is also well known
that the CRUSADE score is valuable in predicting bleeding
risk in NSTEMI patients.
11
However, all of these studies were
performed on ACS patients. Bleeding complications are however
an important problem in patients with stable coronary artery
disease undergoing elective coronary angiography, as well as in
ACS patients.
In this regard, Ndrepepa
et al
. included only patients with
stable coronary artery disease who underwent elective PCI, and
they showed that bleeding within 30 days of the procedure was
associated with an increased risk of one-year mortality after PCI.
These findings suggest that prevention of procedural bleeding
may contribute to PCI outcomes in terms of reducing mortality
rate in patients with stable coronary artery disease.
12
However, in
this study, a scoring system that could predict bleeding was not
used. Our study revealed the predictive value of the HAS-BLED
and CRUSADE scores on the risk of in-hospital bleeding in
patients with stable coronary artery disease.
Although HAS-BLED is mainly used to predict bleeding
risk in AF patients,
4
some previous studies have demonstrated
that it may also predict bleeding risk in patients with coronary
artery disease. In a study conducted on NSTEMI patients,
the HAS-BLED bleeding score was shown to be as effective
as GRACE and CRUSADE, and even better than the TIMI
scoring system with regard to future bleeding risk prediction.
5
In another study, the HAS-BLED score was also found to
be useful in predicting in-hospital major bleeding risk in
NSTEMI patients, together with the CRUSADE and ACUITY-
HORIZONS scores.
6
All these studies have emphasised that the
HAS-BLED score, which is as useful as other scoring systems,
is more practical and easy to apply. The ease of calculating the
HAS-BLED score and its ease of implementation in clinical
practice further increases the importance of this bleeding risk
scoring system.
The CRUSADE score has been studied several times to
predict bleeding risk in patients with coronary artery disease,
especially in NSTEMI patients. In other studies, the CRUSADE
score has been shown to be effective in predicting major bleeding
in patients undergoing PCI,
13,14
and was shown to be even more
valuable than the platelet reactivity test in PCI patients.
15
It can
be used to predict mortality risk, similar to the GRACE risk
score in ACS patients,
16
and to predict bleeding risk in STEMI
patients.
17
The prognostic accuracy of the CRUSADE score can
be used to predict major or moderate bleeding events even in
non-invasively treated ACS patients.
18
It is interesting that such
an impressive scoring system did not give as good predictive
results as the HAS-BLED scoring system in our patient group.
Costa
et al
. showed that the CRUSADE risk score predicted
major bleeding events better than the HAS-BLED score in their
study.
19
However their study differed from ours in that it involved
only patients receiving dual antiplatelet therapy after stenting
and included only major bleeding events. Similar negative
results for the CRUSADE risk score have also been found in
some previous studies. In a study conducted in octogenarians,
it was reported that the CRUSADE score was insufficient to
predict the risk of bleeding in NSTEMI patients and that new
scoring systems were needed.
20
In a study by Correia
et al
., it was
reported that the ACUITY scoring system was a better predictor
of major bleeding in patients admitted to hospital with ACS
compared to the CRUSADE score.
21
These conflicting results suggest that we do not have an ideal
scoring system to use on all patients and that new developments
are needed in this regard. For this reason, in our study we
examined patients with stable coronary artery disease who
underwent elective coronary angiography, since there is little data
on them and they were often overlooked in previous studies. We
included all patients with stable coronary artery disease with or
without stent implantation, and examined the HAS-BLED and
CRUSADE scores, which were not previously studied in this
group.
We have shown that the HAS-BLED score was more
predictive in these patients, even though the results of the
CRUSADE score were reasonable, and that HAS-BLED may
help us to predict bleeding events and reduce co-morbidity in
these patients. The ease of calculating the HAS-BLED score and
its ease of implementation in clinical practice further increases
the importance of this bleeding risk-scoring system. The present
study provides valuable data because this group of patients is
frequently encountered in the angiography laboratory in daily
cardiology practice and there is no scoring system as yet to
predict bleeding risk among these patients.
This study has some limitations, such as it was a single-
centre study with a small sample size and did not include long-
term results. Another limitation is that the femoral artery was
preferred to the radial artery for coronary angiography.
Conclusion
Various scoring systems are used in the prediction of bleeding
risk in patients undergoing angiography due to ACS. However,
in stable angina patients without ACS, there is not enough data
on this subject. This study showed that the HAS-BLED and