Bleeding risk stratification in acute coronary syndromes. Is it still valid in the era of the radial approach?

Bleeding is the most common adverse event after percutaneous coronary intervention (PCI). It can occur either as a direct complication of the index procedure or spontaneously during the antithrombotic treatment for secondary prevention. Hemorrhagic complications significantly impact the prognosis independently from their timing and have been associated with a poorer quality of life [1]. In addition, anti-thrombotic therapies are now becoming more potent than in the past, and an increase in hemorrhagic events can easily be anticipated in clinical practice with state-of-the-art drug combinations. International guidelines endorse a careful evaluation of the bleeding risk, in order to lower the risk of the devastating consequences of hemorrhagic events with the simultaneous effort to maintain ischemic protection. However, no specific methodology has ever been standardized to assess bleeding risk in patients undergoing PCI, although several bleeding risk scores [2–8], addressing risk strati-fication in diverse clinical situations, have gained popularity (Table I). They are based on readily available clinical and laboratory values and could improve clinicians' ability to standardize bleeding risk assessment. Among these, the CRUSADE score [8] was developed from a large registry, which included 71,277 patients with non-ST segment elevation myocardial infarction (NSTEMI), and is recommended by European guidelines for the bleeding stratification of patients with NSTEMI [9]. The CRUSADE score estimates the risk of in-hospital bleeding irrespective of the initial therapeutic strategy, and also confirms its discriminatory capacity in the subgroup of patients managed invasively with PCI [8]. Similarly, the ACUITY score has been developed to appraise in-hospital bleeding risk in a wider acute coronary syndrome (ACS) patient population [3]. Importantly, this score also takes into account the type of anticoagulant used during PCI (i.e. heparin + glycoprotein IIb/IIIa inhibitors or bivaliru-din), considering the protective effect of bivalirudin on peri-procedural bleeding as compared to heparin plus glycoprotein IIb/IIIa inhibitors [3]. In the current issue of Postępy w Kardiologii Interwen-cyjnej/Advances in Interventional Cardiology, the performance of different bleeding risk scores in the PCI scenario is broadly assessed in a meta-analysis [10]. The authors conclude that the appraised risk scores performed similarly in patients with ACS [10]. This result suggests that more important than which score to apply it is to apply at least one. In fact, although these scores focus on slightly different patient populations and clinical/procedural variables , anyone of them can help clinicians to standardize bleeding risk assessment and objectively point out those individuals with a higher bleeding risk. …