Prediction and prognostic importance of in-hospital major bleeding in a real-world cohort of patients with pulmonary embolism

Abstract

Background: Assessment of bleeding risk in patients with pulmonary embolism (PE) is challenging. Recently, the VTE-BLEED score was shown to predict major bleeding. Therefore, we aimed to investigate the VTE-BLEED score and assess the prognostic impact of major bleeding in a real-world cohort of PE patients.

Methods: Consecutive PE patients included in a prospective single-center cohort study between 09/2008 and 11/2016 were eligible for analysis; patients treated with thrombolysis were excluded. The VTE-BLEED was calculated post-hoc; in-hospital major bleeding was defined using the ISTH definition.

Results: Overall, 522 patients (median age 69, IQR 56-78 years; 53% female) were included in the present analysis; major bleeding occurred in 18 (3.5%) patients. A VTE-BLEED score ≥2 points identified patients at high-risk for major bleeding (OR 3.7, 95% CI 1.1-13.0, sensitivity 83%, specificity 42%). Additionally, a GFR <30 ml/min/1.73 m² (OR 6.0, 95% CI 1.8-19.8) and previous surgery (OR 3.6, 95% CI 1.4-9.3) were associated with major bleeding. A less frequent use of unfractionated heparin as initial treatment was associated with a decrease of major bleeding over time. Major bleeding was identified as strong predictor of in-hospital (OR 7.7, 95% CI 2.3-25.8) and 1-year mortality (HR 3.6, 95% CI 2.0-6.6), especially in normotensive patients (OR 12.1, 95% CI 3.5-43.0 and HR 6.0, 95% CI 2.9-12.6, respectively).

Conclusions: In a real-world cohort, the VTE-BLEED score identified PE patients at risk for in-hospital major bleeding. However, for assessment of bleeding risk, renal function and previous surgery should be considered. Major bleeding emerged as strong predictor of in-hospital and 1-year mortality.

Keywords: Bleeding; HAS-BLED score; Prognosis; VTE-BLEED score; Venous thromboembolism.