CRUSADE Score for Post-MI Bleeding Risk

CRUSADE Score for Post-MI Bleeding Risk Stratifies bleeding risk after NSTEMI. Currently, the CRUSADE bleeding risk score recommended for risk stratification for major bleeding in patients presenting with NSTEMI or STEMI prior to initiation of treatment.

Baseline hematocrit:
<31
31-33.9
34-36.9
37-39.9
≥40

Creatinine clearance, mL/min:
≤15
>15-30
>30-60
>60-90
>90-120
>120

Heart rate:
≤70
71-80
81-90
91-100
101-110
111-120
≥121

Sex:
Male
Female

Signs of CHF at presentation:
Yes
No

Diabetes mellitus:
Yes
No

Prior vascular disease:
Yes
No

Systolic blood pressure, mm Hg:
≤90
91-100
101-120
121-180
181-200
≥201



Points Risk category stratification of the major bleeding Score range Risk of major bleeding, %
0 0 0 0

For CRUSADE score assessment provide addition of the selected points.

CriteriaValuePoints
Baseline hematocrit<31+9
 31-33.9+7
 34-36.9+3
 37-39.9+2
 ≥400
Creatinine clearance, mL/min≤15+39
 >15-30+35
 >30-60+28
 >60-90+17
 >90-120+7
 >1200
Heart rate≤700
 71-80+1
 81-90+3
 91-100+6
 101-110+8
 111-120+10
 ≥121+11
SexMale0
 Female+8
Signs of CHF at presentationNo0
 Yes+7
Diabetes mellitusNo0
 Yes+6
Prior vascular diseaseNo0
 Yes+6
Systolic blood pressure, mm Hg≤90+10
 91-100+8
 101-120+5
 121-180+1
 181-200+3
 ≥201+5

If some parameters are within normal ranges:

Heart rateNorm: 60-100beats/min
Systolic BPNorm: 100-120mm Hg
HematocritNorm: 36-51%
Creatinine clearance  Norm: 88-137mL/min
SexFemale +8Male 0
Signs of CHF at presentation Ex: Orthopnea, SOB, DOE, rales, JVD, CXR findings of CHFNo 0Yes +7
History of vascular diseaseNo 0Yes +6
History of diabetes mellitusNo 0Yes +6

Interpretation:

Risk category stratification of the major bleedingScore rangeRisk of major bleeding, %
Very low risk≤203.1%
Low risk21-305.5%
Moderate risk31-408.5%
High risk41-5011.9%
Very high risk>5019.5%

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.

Risks and benefits of anti-thrombotic therapy and invasive treatment should be carefully considered in ALL patients presenting with NSTEMI or STEMI.

Antithrombotic agents reduce ischemic risks in patients with NSTEMI and STEMI. However, 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 NSTEMI patients to facilitate optimal treatment selection. A subsequent study also validated the score in patients with STEMI as well.

Besides, 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 angiography.

The CRUSADE bleeding risk score was subsequently validated in STEMI patients undergoing primary PCI though overall bleeding risk was lower in this population.

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.

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.

 

Alternative bleeding risk scores may also be utilized in certain groups of patients.

Literature:
Subherwal S, Bach RG, Chen AY, Gage BF, Rao SV, Newby LK, Wang TY, Gibler WB, Ohman EM, Roe MT, Pollack CV Jr.,Peterson ED, Alexander KP. Baseline risk of major bleeding in non‐ST‐segment‐elevation myocardial infarction: the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress Adverse outcomes with Early Implementation of the ACC/AHA Guidelines) Bleeding Score. Circulation. 2009; 119:1873-1882 https://pubmed.ncbi.nlm.nih.gov/19332461/
Abu-Assi E, Gracía-Acuña JM, Ferreira-González I, et al. Evaluating the Performance of the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines (CRUSADE) bleeding score in a contemporary Spanish cohort of patients with non-ST-segment elevation acute myocardial infarction. Circulation 2010; 121(22):2419-26 https://pubmed.ncbi.nlm.nih.gov/20497978/
Abu-Assi E, Raposeiras-Roubin S, Lear P, et al. Comparing the predictive validity of three contemporary bleeding risk scores in acute coronary syndrome. Eur Heart J Acute Cardiovasc Care 2012; 1(3):222-31 https://pubmed.ncbi.nlm.nih.gov/24062910/
Ariza-Solé A, Sánchez-Elvira G, Sánchez-Salado JC, et al. CRUSADE bleeding risk score validation for ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention. Thromb Res 2013; 132(6):652-8 https://pubmed.ncbi.nlm.nih.gov/24112751/
Flores-Ríos X, Couto-Mallón D, Rodríguez-Garrido J, et al. Comparison of the performance of the CRUSADE, ACUITY-HORIZONS, and ACTION bleeding risk scores in STEMI undergoing primary PCI: insights from a cohort of 1391 patients. Eur Heart J Acute Cardiovasc Care 2013; 2(1):19-26 https://pubmed.ncbi.nlm.nih.gov/24062930/

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