Does the AIMS65, a new risk score for upper gastrointestinal bleeding, work in Japan?

Comparison of three scoring systems in predicting clinical outcomes in patients with acute upper gastrointestinal bleeding: a prospective observational study

OBJECTIVE

To compare the performances of the Glasgow-Blatchford score (GBS), modified GBS (mGBS) and AIMS65 in predicting clinical outcomes in patients with acute upper gastrointestinal bleeding (AUGIB).

METHODS

This study enrolled 320 consecutive patients with AUGIB. Patients at high and low risks of developing adverse clinical outcomes (rebleeding, the need of clinical intervention and death) were categorized according to the GBS, mGBS and AIMS65 scoring systems. The outcome of the patients were the occurrences of adverse clinical outcomes. The areas under the receiver operating characteristics curve (AUROC) of three scoring systems were compared.

RESULTS

Irrespective of the systems used, the high-risk groups showed higher rates of rebleeding, intervention and death compared with the low-risk groups (P < 0.05). For the prediction of rebleeding, AIMS65 (AUROC 0.735, 95% CI 0.667-0.802) performed significantly better than GBS (AUROC 0.672, 95% CI 0.597-0.747; P < 0.01) and mGBS (AUROC 0.677, 95% CI 0.602-0.753; P < 0.01). For the prediction of interventions, there was no significant difference among the three systems (GBS: AUROC 0.769, 95% CI 0.668-0.870; mGBS: AUROC 0.745, 95% CI 0.643-0.847; AIMS65: AUROC 0.746, 95% CI 0.640-0.851). For the prediction of in-hospital mortality, there was no significant difference among the three systems (GBS: AUROC 0.796, 95% CI 0.694-0.898; mGBS: AUROC 0.803, 95% CI 0.703-0.904; AIMS65: AUROC 0.786, 95% CI 0.670-0.903).

CONCLUSIONS

The three scoring systems are reliable and accurate in predicting the rates of rebleeding, surgery and mortality in AUGIB. However, AIMS65 outperforms GBS and mGBS in predicting rebleeding.

Significance of AIMS65 risk scoring system in evaluating prognosis of acute upper gastrointestinal bleeding

AIM

To assess the value of AIMS65 risk scoring system for evaluating the risk of rebleeding and mortality with acute variceal upper gastrointestinal bleeding (AVUGIB) and acute non-variceal upper gastrointestinal bleeding (ANVUGIB).

METHODS

Clinical data for 339 acute upper gastrointestinal bleeding (AUGIB) patients treated from October 2013 to June 2016 at the First Affiliated Hospital of Zhengzhou University who met the inclusion criteria and had complete information were included. Each patient's score of AIMS65 was calculated. Patients were followed for 30 d after discharge. Death or the prognosis of disease in 30 d after discharge was considered as the clinical study endpoint. The rates of rebleeding and mortality were calculated. The area under the receiver operating characteristic curve (AUC) of AIMS65 risk scoring system was calculated to verify its efficiency in evaluating rebleeding and mortality.

RESULTS

With the increase in AIMS65 risk scores, the rates of rebleeding and mortality increased in AUGIB patients. The AUCs of AIMS65 risk scoring system for assessing the rates of rebleeding and mortality in AVUGIB were 0.717 (95%CI: 0.568-0.866, P < 0.05) and 0.857 (95%CI: 0.747-0.967, P < 0.05), respectively. The AUCs of AIMS65 risk scoring system for assessing the rates of rebleeding and mortality in ANVUGIB were 0.768 (95%CI: 0.652-0.884, P < 0.05) and 0.857 (95%CI: 0.733-0.981, P < 0.05), respectively.

CONCLUSION

AIMS65 risk scoring system can be used to predict the risk and assess the prognosis of AUGIB, including both ANVUGIB and AVUGIB.

Upper gastrointestinal bleeding risk scores: Who, when and why?

Upper gastrointestinal bleeding (UGIB) remains a significant cause of hospital admission. In order to stratify patients according to the risk of the complications, such as rebleeding or death, and to predict the need of clinical intervention, several risk scores have been proposed and their use consistently recommended by international guidelines. The use of risk scoring systems in early assessment of patients suffering from UGIB may be useful to distinguish high-risks patients, who may need clinical intervention and hospitalization, from low risk patients with a lower chance of developing complications, in which management as outpatients can be considered. Although several scores have been published and validated for predicting different outcomes, the most frequently cited ones are the Rockall score and the Glasgow Blatchford score (GBS). While Rockall score, which incorporates clinical and endoscopic variables, has been validated to predict mortality, the GBS, which is based on clinical and laboratorial parameters, has been studied to predict the need of clinical intervention. Despite the advantages previously reported, their use in clinical decisions is still limited. This review describes the different risk scores used in the UGIB setting, highlights the most important research, explains why and when their use may be helpful, reflects on the problems that remain unresolved and guides future research with practical impact.

Clinical Application of AIMS65 Scores to Predict Outcomes in Patients with Upper Gastrointestinal Hemorrhage

BACKGROUND/AIMS

To evaluate the ability of the recently proposed albumin, international normalized ratio (INR), mental status, systolic blood pressure, age >65 years (AIMS65) score to predict mortality in patients with acute upper gastrointestinal bleeding (UGIB).

METHODS

AIMS65 scores were calculated in 251 consecutive patients presenting with acute UGIB by allotting 1 point each for albumin level <30 g/L, INR >1.5, alteration in mental status, systolic blood pressure ≤90 mm Hg, and age ≥65 years. Risk stratification was done during the initial 12 hours of hospital admission.

RESULTS

Intensive care unit (ICU) admission, endoscopic therapy, or surgery were required in 51 patients (20.3%), 64 (25.5%), and 12 (4.8%), respectively. The predictive accuracy of AIMS65 scores ≥2 was high for blood transfusion (area under the receiver operator characteristic curve [AUROC], 0.59), ICU admission (AUROC, 0.61), and mortality (AUROC, 0.74). The overall mortality was 10.3% (n=26), and was 3%, 7.8%, 20%, 36%, and 40% for AIMS65 scores of 0, 1, 2, 3, and 4, respectively; these values were significantly higher in those with scores ≥2 (30.9%) than in those with scores <2 (4.5%, p<0.001).

CONCLUSIONS

AIMS65 is a simple, accurate, non-endoscopic risk score that can be applied early (within 12 hours of hospital admission) in patients with acute UGIB. AIMS65 scores ≥2 predict high in-hospital mortality.

Comparison of the Glasgow-Blatchford and AIMS65 scoring systems for risk stratification in upper gastrointestinal bleeding in the emergency department

OBJECTIVES

The aim of this study was to compare the performance of the Glasgow-Blatchford and the AIMS65 scoring systems as early risk assessment tools for accurately identifying patients with upper gastrointestinal (GI) bleeding who are at a low risk of requiring clinical interventions, including emergency endoscopy. The secondary objective was to compare their performance regarding relevant clinical outcomes.

METHODS

Data were collected prospectively over a 2-year period in the emergency department of a university hospital. Adult patients with upper GI bleeding from either variceal or nonvariceal sources were included. Composite clinical outcomes consisted of a need for surgical or endoscopic intervention, rebleeding, intensive care unit admission, or in-hospital mortality. Patients who required blood transfusions or suffered composite clinical outcomes were considered high-risk patients. Glasgow-Blatchford score (GBS) and AIMS65 score were calculated for each patient. The sensitivity and specificity of the scoring systems were calculated. The areas under the receiver-operating characteristic curve (AUC) of the scores were compared.

RESULTS

There were 254 patients in the study, of whom 163 (64.2%) were men. The median age was 61 years (interquartile range = 45 to 72 years). Among the patients, 211 (83.1%) underwent endoscopy, of whom 49 (19.3%) required endoscopic intervention to achieve hemostasis. Five (2%) patients required surgical intervention. Rebleeding was observed in 33 (13%) patients. A total of 143 (56.3%) patients received blood transfusions. A total of 152 (59.8%) were defined as high risk. Eighty-one (31.9%) experienced at least one component of the composite clinical outcomes, 18 (7.1%) of whom suffered in-hospital mortality. A GBS of 0 was observed in 16 patients (6.3%) in the study group. Two of these were high-risk patients. A total of 101 (39.8%) patients had AIMS65 scores of 0. Thirty-four of these were high-risk patients. A GBS of 0 had higher sensitivity than an AIMS65 score of 0 (98.68% vs. 77.6%). The negative predictive values of the GBS and AIMS65 of 0 were 87.5 and 66.3%, respectively. The GBS and AIMS65 were similar with regard to the composite outcome prediction, with AUCs of 0.795 (95% confidence interval [CI] = 0.74 to 0.843) and 0.746 (95% CI = 0.688 to 0.798), respectively (p = 0.137). The scores were also similar with respect to predicting in-hospital mortality (AUCs of 0.85 vs. 0.81; p = 0.342). The GBS was superior to the AIMS65 in identifying high-risk patients, with AUCs of 0.896 (95% CI = 0.85 to 0.93) and 0.771 (95% CI = 0.714 to 0.821; p < 0.001), respectively. The GBS was also more accurate than the AIM65 in predicting the need for blood transfusions (AUCs of 0.904 vs. 0.796; p < 0.001) and interventions (AUCs of 0.727 vs. 0.647; p = 0.05).

CONCLUSIONS

These results suggest that the GBS has superior sensitivity relative to the AIMS65 in identifying patients who were not likely to require interventions, including emergency endoscopy. Additional work to determine the use in real-time decision making may be warranted and helpful in providing guidance to clinicians.