PLoS ONE (Jan 2018)

Predictive ability of scores for bleeding risk in heart disease outpatients on warfarin in Brazil.

  • João Antonio de Queiroz Oliveira,
  • Antonio Luiz Pinho Ribeiro,
  • Daniel Dias Ribeiro,
  • Vandack Nobre,
  • Manoel Otávio da Costa Rocha,
  • Maria Auxiliadora Parreiras Martins

DOI
https://doi.org/10.1371/journal.pone.0205970
Journal volume & issue
Vol. 13, no. 10
p. e0205970

Abstract

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INTRODUCTION:Bleeding is a common complication in patients taking warfarin. We sought to compare the performance of nine prediction models for bleeding risk in warfarin-treated Brazilian outpatients. METHODS:The dataset was derived from a clinical trial conducted to evaluate the efficacy of an anticoagulation clinic at a public hospital in Brazil. Overall, 280 heart disease outpatients taking warfarin were enrolled. The prediction models OBRI, Kuijer et al., Kearon et al., HEMORR2HAGES, Shireman et al., RIETE, HAS-BLED, ATRIA and ORBIT were compared to evaluate the overall model performance by Nagelkerke's R2 estimation, discriminative ability based on the concordance (c) statistic and calibration based on the Hosmer-Lemeshow goodness-of-fit statistic. The primary outcomes were the first episodes of major bleeding, clinically relevant non-major bleeding and non-major bleeding events within 12 months of follow-up. RESULTS:Major bleeding occurred in 14 participants (5.0%), clinically relevant non-major bleeding in 29 (10.4%), non-major bleeding in 154 (55.0%) and no bleeding at all in 115 (41.1%). Most participants with major bleeding had their risk misclassified. All the models showed low overall performance (R2 0.6-9.3%) and poor discriminative ability for predicting major bleeding (c <0.7), except Shireman et al. and ORBIT models (c 0.725 and 0.719, respectively). Results were not better for predicting other bleedings. All models showed good calibration for major bleeding. CONCLUSIONS:Only two models (Shireman et al. and ORBIT) showed at least acceptable performance in the prediction of major bleeding in warfarin-treated Brazilian patients. Accurate models warrant further investigation to be used in similar populations.