Bleeding by the numbers: The utility and the limitations of bleeding scores, bleeding prediction tools, and bleeding case definitions


      A patient’s history of bleeding, whether spontaneous or in response to challenges, provides important information about both the likelihood of that patient having a biochemically-defined hemostatic defect, and that patient’s risk of future bleeding. Other variables including age, comorbidities and medications influence these probabilities. Scoring systems have been devised in an effort to make the estimates quantitative in specific populations. An example of a bleeding score is the MCMDM1-VWD questionnaire, which was developed to predict the likelihood of a patient having von Willebrand disease. It sums standardized details of the bleeding history, weighted by severity. The HAS-BLED score typifies bleeding prediction tools, developed to predict bleeding during anticoagulant therapy. Although prior bleeding is one item in this score, other comorbidities like hypertension or a history of stroke count for more. A third and related concept is that of bleeding case definitions, which are critical to standardize the reporting of outcomes in trials of antithrombotic agents, and which have entrenched the recognition of different severities of bleeding. We advocate that future efforts should blend some of these features. Information about comorbidities and medication use could refine the interpretation of bleeding events in a bleeding score. So could the introduction of a denominator reflecting the number and duration of challenges to which the patient has been exposed when bleeding might have been expected. More detailed information about the type, frequency and severity of prior bleeding could improve the prognostic power of bleeding prediction tools. More detailed history-based scores might ultimately supersede biochemical testing in many cases.
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        • Tosetto A.
        • Rodeghiero F.
        • Castaman G.
        • Goodeve A.
        • Federici A.B.
        • Batlle J.
        • et al.
        A quantitative analysis of bleeding symptoms in type 1 von willebrand disease: results from a multicenter European study (MCMDM-1 VWD).
        J Thromb Haemost : JTH. 2006; 4: 766-773
        • Pisters R.
        • Lane D.A.
        • Nieuwlaat R.
        • de Vos C.B.
        • Crijns H.J.
        • Lip G.Y.
        A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro heart survey.
        Chest. 2010; 138: 1093-1100
        • Chesebro J.H.
        • Knatterud G.
        • Roberts R.
        • Borer J.
        • Cohen L.S.
        • Dalen J.
        • et al.
        Thrombolysis in myocardial infarction (TIMI) trial, phase I: a comparison between intravenous tissue plasminogen activator and intravenous streptokinase. Clinical findings through hospital discharge.
        Circulation. 1987; 76: 142-154
        • Schulman S.
        • Kearon C.
        Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients.
        J Thromb Haemost: JTH. 2005; 3: 692-694
        • Kaatz S.
        • Ahmad D.
        • Spyropoulos A.C.
        • Schulman S.
        Definition of clinically relevant non‐major bleeding in studies of anticoagulants in atrial fibrillation and venous thromboembolic disease in non‐surgical patients: communication from the SSC of the ISTH.
        J Thromb Haemost. 2015; 13: 2119-2126
        • Connolly S.J.
        • Ezekowitz M.D.
        • Yusuf S.
        • Eikelboom J.
        • Oldgren J.
        • Parekh A.
        • et al.
        Dabigatran versus warfarin in patients with atrial fibrillation.
        N Engl J Med. 2009; 361: 1139-1151
        • Rodeghiero F.
        • Castaman G.
        • Tosetto A.
        • Batlle J.
        • Baudo F.
        • Cappelletti A.
        • et al.
        The discriminant power of bleeding history for the diagnosis of type 1 von willebrand disease: an international, multicenter study.
        J Thromb Haemost: JTH. 2005; 3: 2619-2626
        • Rodeghiero F.
        • Tosetto A.
        • Abshire T.
        • Arnold D.M.
        • Coller B.
        • James P.
        • et al.
        ISTH/SSC bleeding assessment tool: a standardized questionnaire and a proposal for a new bleeding score for inherited bleeding disorders.
        J Thromb Haemost: JTH. 2010; 8: 2063-2065
        • Deforest M.
        • Grabell J.
        • Albert S.
        • Young J.
        • Tuttle A.
        • Hopman W.M.
        • et al.
        Generation and optimization of the self-administered bleeding assessment tool and its validation as a screening test for von willebrand disease.
        Haemophilia. 2015; 21: e384-8
        • Bowman M.L.
        • James P.D.
        Bleeding scores for the diagnosis of Von Willebrand disease.
        Semin Thromb Hemost. 2017; 43: 530-539
        • O’Brien S.H.
        Bleeding scores: are they really useful?.
        Hematol Am Soc Hematol Educ Program. 2012; 2012: 152-156
        • Rodeghiero F.
        • Castaman G.
        • Dini E.
        Epidemiological investigation of the prevalence of von Willebrand’s disease.
        Blood. 1987; 69: 454-459
        • Bowman M.
        • Mundell G.
        • Grabell J.
        • Hopman W.M.
        • Rapson D.
        • Lillicrap D.
        • et al.
        Generation and validation of the condensed MCMDM-1VWD bleeding questionnaire for von Willebrand disease.
        J Thromb Haemost: JTH. 2008; 6: 2062-2066
        • Tosetto A.
        • Castaman G.
        • Plug I.
        • Rodeghiero F.
        • Eikenboom J.
        Prospective evaluation of the clinical utility of quantitative bleeding severity assessment in patients referred for hemostatic evaluation.
        J. Thromb Haemost: JTH. 2011; 9: 1143-1148
        • Azzam H.A.
        • Goneim H.R.
        • El-Saddik A.M.
        • Azmy E.
        • Hassan M.
        • El-Sharawy S.
        The condensed MCMDM-1 VWD bleeding questionnaire as a predictor of bleeding disorders in women with unexplained menorrhagia.
        Blood Coagul Fibrinol. 2012; 23: 311-315
        • Bowman M.
        • Riddel J.
        • Rand M.L.
        • Tosetto A.
        • Silva M.
        • James P.D.
        Evaluation of the diagnostic utility for von Willebrand disease of a pediatric bleeding questionnaire.
        J Thromb Haemost : JTH. 2009; 7: 1418-1421
        • Biss T.T.
        • Blanchette V.S.
        • Clark D.S.
        • Bowman M.
        • Wakefield C.D.
        • Silva M.
        • et al.
        Quantitation of bleeding symptoms in children with von Willebrand disease: use of a standardized pediatric bleeding questionnaire.
        J Thromb Haemost: JTH. 2010; 8: 950-956
        • Elbatarny M.
        • Mollah S.
        • Grabell J.
        • Bae S.
        • Deforest M.
        • Tuttle A.
        • et al.
        Normal range of bleeding scores for the ISTH-BAT: adult and pediatric data from the merging project.
        Haemophilia. 2014; 20: 831-835
        • Rodger M.A.
        • Kahn S.R.
        • Wells P.S.
        • Anderson D.A.
        • Chagnon I.
        • Le Gal G.
        • et al.
        Identifying unprovoked thromboembolism patients at low risk for recurrence who can discontinue anticoagulant therapy.
        Cmaj. 2008; 179: 417-426
        • Garcia J.
        • Christopherson P.A.
        • Flood V.H.
        • Gill J.C.
        • Montgomery R.R.
        • James P.D.
        • et al.
        Contribution of select ISTH-BAT subscores to the total score in type 1 VWD.
        Blood. 2017; 130: 1075
        • Spradbrow J.
        • Letourneau S.
        • Grabell J.
        • Liang Y.
        • Riddel J.
        • Hopman W.
        • et al.
        Use of bleeding assessment tools in the diagnosis of Von Willebrand disease: are we asking the right questions?.
        Blood. 2017; 130: 2369
        • Sokal J.E.
        Prognosis in chronic myeloid leukaemia: biology of the disease vs. Treatment.
        Bailliere’s Clin Haematol. 1987; 1: 907-929
        • Sramek A.
        • Eikenboom J.C.
        • Briet E.
        • Vandenbroucke J.P.
        • Rosendaal F.R.
        Usefulness of patient interview in bleeding disorders.
        Arch Intern Med. 1995; 155: 1409-1415
        • de Wee E.M.
        • Sanders Y.V.
        • Mauser-Bunschoten E.P.
        • van der Bom J.G.
        • Degenaar-Dujardin M.E.
        • Eikenboom J.
        • et al.
        Determinants of bleeding phenotype in adult patients with moderate or severe von Willebrand disease.
        Thromb Haemost. 2012; 108: 683-692
        • Tosetto A.
        • Castaman G.
        • Rodeghiero F.
        Bleeders, bleeding rates, and bleeding score.
        J Thromb Haemost : JTH. 2013; 11: 142-150
        • Fang M.C.
        • Go A.S.
        • Chang Y.
        • Borowsky L.H.
        • Pomernacki N.K.
        • Udaltsova N.
        • et al.
        A new risk scheme to predict warfarin-associated hemorrhage: the ATRIA (anticoagulation and risk factors in atrial fibrillation) study.
        J Am Coll Cardiol. 2011; 58: 395-401
        • O’Brien E.C.
        • Simon D.N.
        • Thomas L.E.
        • Hylek E.M.
        • Gersh B.J.
        • Ansell J.E.
        • et al.
        The ORBIT bleeding score: a simple bedside score to assess bleeding risk in atrial fibrillation.
        Eur Heart J. 2015; 36: 3258-3264
        • Federici A.B.
        • Bucciarelli P.
        • Castaman G.
        • Mazzucconi M.G.
        • Morfini M.
        • Rocino A.
        • et al.
        The bleeding score predicts clinical outcomes and replacement therapy in adults with von Willebrand disease.
        Blood. 2014; 123: 4037-4044
        • Prandoni P.
        • Noventa F.
        • Ghirarduzzi A.
        • Pengo V.
        • Bernardi E.
        • Pesavento R.
        • et al.
        The risk of recurrent venous thromboembolism after discontinuing anticoagulation in patients with acute proximal deep vein thrombosis or pulmonary embolism. A prospective cohort study in 1,626 patients.
        Haematologica. 2007; 92: 199-205
        • Fasulo M.R.
        • Biguzzi E.
        • Abbattista M.
        • Stufano F.
        • Pagliari M.T.
        • Mancini I.
        • et al.
        The ISTH bleeding assessment tool and the risk of future bleeding.
        J Thromb Haemost: JTH. 2018; 16: 125-130