Predicting performance of the HAS-BLED and ORBIT bleeding risk scores in patients with atrial fibrillation treated with Rivaroxaban: Observations from the prospective EMIR Registry

BACKGROUND

Assessing bleeding risk during the decision-making process of starting oral anticoagulation (OAC) therapy in atrial fibrillation (AF) patients is essential. Several bleeding risk scores have been proposed for vitamin K antagonist users but, few studies have focused on validation of these bleeding risk scores in patients taking direct oral anticoagulants (DOACs). The aim was to compare the predictive ability of HAS-BLED and ORBIT bleeding risk scores in AF patients taking rivaroxaban in the EMIR ('Estudio observacional para la identificación de los factores de riesgo asociados a eventos cardiovasculares mayores en pacientes con fibrilación auricular no valvular tratados con un anticoagulante oral directo [Rivaroxaban]) Study.

METHODS AND RESULTS

EMIR Study was an observational, multicenter, post-authorization, and prospective study that involved AF patients under OAC with rivaroxaban at least 6 months before enrolment. We analysed baseline clinical characteristics and adverse events after 2.5 years of follow-up and validated the predictive ability of HAS-BLED and ORBIT scores for major bleeding (MB) events.We analysed 1433 patients with mean age of 74.2 ± 9.7 (44.5% female). Mean HAS-BLED score was 1.6 ± 1.0 and ORBIT score was 1.1 ± 1.2. The ORBIT score categorised a higher proportion of patients as 'low-risk' (87.1%) compared with 53.5% using the HAS-BLED score. There were 33 MB events (1.04%/year) and 87 patients died (2.73%/year). Both HAS-BLED and ORBIT had a good predictive ability for MB{Area under the curve (AUC) 0.770, [95% confidence interval (CI) 0.693-0.847; P <0.001] and AUC 0.765 (95% CI 0.672-0.858; P <0.001), respectively}. There was a non-significant difference for discriminative ability of the two tested scores (P = 0.930) and risk reclassification in terms of net reclassification improvement (NRI) -5.7 (95% CI -42.4-31.1; P = 0.762). HAS-BLED score showed the best calibration and ORBIT score showed the largest mismatch in calibration, particularly in higher predicted risk patients.

CONCLUSION

In a prospective real-world AF population under rivaroxaban from EMIR registry, the HAS-BLED score had good predictive performance and calibration compared with ORBIT score for MB events. ORBIT score presented worse calibration than HAS-BLED in this DOAC treated population.

POS0868 THE DEVELOPMENT OF THE LINEAR CRISS; A CLINICAL AND PATIENT MEANINGFUL ANCHOR TO THE ACR-CRISS IN SCLERODERMA

Background

The ACR Composite Response Index in Systemic Sclerosis (ACR-CRISS) is one of the first composite outcome measures in diffuse cutaneous Systemic sclerosis (dcSSc).1 It relies on validated clinical domains selected through a data-driven methodology; however, it only provides a probability of response and is unable to differentiate between patients who do not improve and who worsen respectively.

Objectives

To improve the clinical interpretation of the ACR-CRISS by creating a continuous ranked score of clinically and patient meaningful changes of its individual measures.

Methods

Following OmerACT guidelines for outcome measurement development, relevant stakeholders were identified from 5 continents, including 100 physicians with proven experience in managing patients with dcSSc and 100 patients with dcSSc who have participated in at least one clinical trial. An adaptive conjoint analysis survey based on the PAPRIKA method2 and implemented using 1000minds software was administered. Patients and doctors were asked to choose which of two hypothetical patients had a better or worse outcome according to Minimally Clinical Important Differences (MCID) in two domains at a time from FVC, HAQ-DI and mRSS and the presence of organ failure. These pairwise choices were analysed to rank and weight the MCIDs against each other. With patient and public involvement, utilising a ‘think aloud’ approach, a video tutorial was produced explaining the objectives and process of the adaptive survey to the participants.

Results

Eighty rheumatologists and 80 patients with dcSSc completed the survey, which ran from June 2020 to January 2021. From the survey, relative weights for the 4 domains, reflecting their relative importance with respect to improving and worsening outcomes, were determined. A continuous composite ranked score reflecting the relative weighting of the individual outcome measures (Ranked Composite Important Difference, RCID) was developed accordingly (Table 1). The score ranges from -1 (worst possible outcome) to 1 (best possible outcome), in patients who experience no organ failure and do not meet any MCID in any of the 3 domains scoring 0.

Table 1.

The relative median weights of each of the core set measures within the better and worse outcome models, expressed as a score from -1 to 1

Worsening weightsImprovement weightsDoctorsPatientsCombinedDoctorsPatientsCombinedOrgan failure-0.355-0.333-0.326N/AN/AN/AFVC-0.324-0.306-0.3160.4630.4520.451mRSS-0.205-0.229-0.2170.3200.3200.324HAQ-DI-0.114-0.115-0.1410.2000.2270.224

Conclusion

This collaborative process using a novel, robust methodology and involving both rheumatologists and patients has created a clinically and patient meaningful composite score that can be used as an anchor to the ACR-CRISS, or other clinical outcomes. Performance against the ACR-CRISS and revised CRISS in randomised controlled trials and in observational cohorts will determine the clinical value of the RCID.

References

[1]Khanna D, et al. A&R 2016;68:299–311

[2]Hansen P, Ombler F. Multi-Criteria Decis. Anal 2008;15:87–107

Acknowledgements

DK and FDG are recognised as joint senior authors. The authors acknowledge the doctors and patients involved in the Linear Criss working group: Giuseppina Abignano, Paolo Airò, Dina-Marie Aiuto, Yannick Allanore, Shervin Assassi, Jérôme Avouac, Gianluca Bagnato, Alexandra Balbir-Gurman, Silvia Bellando Randone,Lorenzo Beretta, Elana Bernstein, Silvia Laura Bosello, Yolanda Braun Moscovici, Katrina Brown, Maya Buch, Corrado Campochiaro, Patricia Carreira, Lorinda Chung, Julia Coakes, Mary Cox, Giovanna Cuomo, Maurizio Cutolo, Laszlo Czirjak, Lorenzo Dagna, Giacomo De Luca, Nicoletta Del Papa, Christopher Denton, Emma Derrett-Smith, Robyn Domsic, Raluca-Bianca Dumitru, Victoria Flower, Ivan Foeldvari, Armando Gabrielli, Yasir Ghaffar, Roberto Giacomelli, Dilia Giuggioli, Daisy Gonzalez, Jessica Gordon, Yvonne Gouldstone, Marie Hudson, Francesca Ingegnoli, Lorraine Jackson, Sergio Jimenez, Terrance Johnson, Bashar Kahaleh, Robin King, Otylia Kowal-Bielecka, Masataka Kuwana, Maria Lazzaroni, Alain Lescoat, Takashi Matsushita, Marco Matucci Cerinic, Maureen Mayes, Thomas Medsger, Francesca Menegazzi, Tünde Minier, Mandana Nikpour, Chris O’Hora, Emese Paári-Molnár, John Pauling, Jose Antonio Pereira da Silva, Mercè Piñero Vegas, Janet Pope, Susanna Proudman, Ismaila Rafiq, Valeria Riccieri, Tatiana Sofia Rodriguez-Reyna, Tânia Santiago, James Seibold, Richard Silver, Robert Spiera, Tracy Stafford, Virginia Steen, Yossra Atef Suliman. Madelon Vonk, Ian Wright.

Disclosure of Interests

Lesley-Anne Bissell Speakers bureau: UCB, Abbvie, Galapagos, Daniel Furst: None declared, Sindhu Johnson: None declared, Paul Hansen: None declared, Esmeralda Recalde: None declared, Dinesh Khanna: None declared, Francesco Del Galdo Speakers bureau: Abbvie, AstraZeneca, Boehringer-Ingelheim, Capella Biosciences, Chemomab LTD, Janssen, Kymab LTD, Mitsubishi-Tanabe., Consultant of: Abbvie, AstraZeneca, Boehringer-Ingelheim, Capella Biosciences, Chemomab LTD, Janssen, Kymab LTD, Mitsubishi-Tanabe., Grant/research support from: Abbvie, AstraZeneca, Boehringer-Ingelheim, Capella Biosciences, Chemomab LTD, Janssen, Kymab LTD, Mitsubishi-Tanabe.

Predictors of adverse clinical outcomes in atrial fibrillation patients with concomitant renal impairment under rivaroxaban therapy

Background

Atrial fibrillation (AF) increases the risk of stroke and mortality, and concomitant renal impairment confers a worse prognosis. However, those factors that may limit the use of direct-acting oral anticoagulants in AF patients with renal impairment have not been further investigated, as they confer a higher risk of adverse events in this patient population.

Purpose

To investigate predictors of adverse clinical outcomes in AF patients with renal impairment who were treated with rivaroxaban.

Methods

The EMIR study is an observational, multicenter study including patients with AF treated with rivaroxaban for at least the previous 6 months. During 2.5 years of follow-up, the occurrence of thromboembolic events (the composite of isquemic stroke, transient ischemic attack, systemic embolism and myocardial infarction [MI]), major bleeding (ISTH definition) and major adverse cardiovascular events (MACE: fatal/non-fatal MI, myocardial revascularization and cardiovascular death) were recorded. For the present analysis, creatinine clearance (CrCl) was estimated by using the Cockroft-Gault equation and renal impairment was defined as a CrCl &lt;60 mL/min.

Results

1433 patients were included (44.5% female; mean age 74.2±9.7 years), of which 498 (35.1%) had CrCl &lt;60 mL/min. The mean CHA2DS2-VASc and HAS-BLED were 3.5±1.5 and 1.6±1.0, respectively. During the follow-up, 7 (1.4%) patients with CrCl &lt;60 mL/min suffered a thromboembolic event, 16 (3.2%) suffered major bleeding, and 19 (3.8%) suffered a MACE. Compared to patients with normal renal function, patients with CrCl &lt;60 mL/min showed a higher annual rate of major bleeding (0.62%/year vs. 1.87%/year; p=0.003) and MACE (0.62%/year vs. 1.97%/year; p=0.002). Multivariate analyses demonstrated that the CHA2DS2-VASc score (OR 1.84; 95% CI 1.11–3.07) was associated with a higher risk of thromboembolic events; whereas the HAS-BLED score (OR 2.25; 95% CI 1.41–3.59) and any dependency level (OR 3.42; 95% CI 1.17–9.98) were associated with a higher risk of major bleeding; and male sex (OR 3.55; 95% CI 1.08–11.63) and heart failure (OR 4.67; 95% CI 1.62–13.51) with a higher risk of MACE. The use of antiplatelet agents was also independently associated with an increased risk of thromboembolic events and MACE (OR 12.28; 95% CI 2.50–60.18; and OR 8.72; 95% CI 2.86–26.59; respectively).

Conclusions

Rivaroxaban showed excellent results in moderate renal impairment. However, the annual rate of major bleeding and MACE was higher in AF patients with impaired renal function. In patients with AF and renal impairment, male sex, the presence of heart failure, dependency, the concomitant use of antiplatelets, and greater comorbidity according to the CHA2DS2-VASc and HAS-BLED, were associated with higher risk of adverse clinical outcomes.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Bayer

Mortality in a cohort of complex patients with chronic illnesses and multimorbidity: a descriptive longitudinal study

Background

Certain advanced chronic conditions (heart failure, chronic lung disease) are associated with high mortality. Nevertheless, most of the time, patients with these conditions are not given the same level of attention or palliative care as those with cancer.

The objective of this study was to assess mortality and its association with other variables in a cohort of complex multimorbid patients with heart failure and/or lung disease from two consecutive telemonitoring studies.

Methods

This multicentre longitudinal study was conducted between 2010 and 2015. We included 83 patients (27 without telemonitoring) with heart failure and/or lung disease with > 1 hospital admission in the previous year and great difficulties leaving home or were housebound. The following variables were indicators of their complex clinical condition: old age (mean: 81 years), comorbidity (Charlson Comorbidity Index score ≥ 2: 86.2 %), both conditions concurrently (54.2 %) and home oxygen therapy (52 %).

We assessed mortality (rate, cause and place of death) and its association with: age, sex, telemonitoring, functional status (Barthel score), quality of life (EQ-5D visual analogue scale), number of medications, and all-cause and condition-specific (due to conditions prompting inclusion) admissions during the previous year. Uni- and bivariate analysis and logistic regression were performed, considering p < 0.05 significant.

Results

A total of 61 patients died within 5 years, representing 31.2 %/year (95 % CI: 23–40.1 %), considering the overall follow-up (sum of individual follow-up days). Of these, 81 % of deaths (95 % CI: 69.1–89–1 %) were due to the condition prompting inclusion, and 83.3 % (95 % CI: 72–90.7 %) died in hospital (median: 8.5 days).

Mortality was lower among those under telemonitoring (p = 0.027), and with fewer condition-specific admissions the previous year (p = 0.006); the latter also showed the strongest association in the multivariate analysis (Exp(B) = 6.115).

Conclusions

Complex patients with multimorbidity had a high mortality rate, generally dying due to the condition for which they had been included, and in hospital (83.3 %). New approaches for managing such patients should be considered, introducing palliative care as required, and using more comprehensive predictors of mortality (functional status and quality of life), together with those related to the illness itself (previous admissions, progression and symptoms).

Large changes in Pluto's atmosphere as revealed by recent stellar occultations

Pluto's tenuous nitrogen atmosphere was first detected by the imprint left on the light curve of a star that was occulted by the planet in 1985 (ref. 1), and studied more extensively during a second occultation event in 1988 (refs 2-6). These events are, however, quite rare and Pluto's atmosphere remains poorly understood, as in particular the planet has not yet been visited by a spacecraft. Here we report data from the first occultations by Pluto since 1988. We find that, during the intervening 14 years, there seems to have been a doubling of the atmospheric pressure, a probable seasonal effect on Pluto.