Bleeding prediction scores may help guide acute management of patients with pulmonary embolism (PE). However existing scoring systems have not been validated for in-hospital assessment. We compared 6 available bleeding scores for the prediction of major bleeding in the in-hospital phase in a real-life cohort.

We recorded in-hospital characteristics of 2754 PE patients included in a prospective observational multicenter cohort study contributing 18,028 person-days of follow-up. The VTE-BLEED, RIETE, ORBIT, HEMORR²HAGES, ATRIA, and HAS-BLED scores were assessed at baseline. ISTH-defined bleeding events were independently adjudicated. The accuracy of the overall, original 3-level and newly defined optimal 2-level outcome of the scores were evaluated and compared.

We observed 82 first in-hospital major bleeding events [3.0% (95% CI, 2.4–3.7)]. Overall, the predictive power of bleeding scores was poor, with a Harrel's C index ranging from 0.57 to 0.69. The Riete score had the numerically highest model fit and discrimination capacity but without reaching statistical significance versus the ORBIT, HEMORR²HAGES, and ATRIA scores. The VTE-BLEED and HAS-BLED scores had significantly lower C indices, integrated discrimination improvement, and net reclassification improvement compared to the others. The rate of observed in-hospital major bleeding in score-defined low-risk patients was high, at between 15% to 34%.

Current available scoring systems are not sufficiently accurate for the prediction of in-hospital major bleeding in patients with acute PE. There is a need to develop risk scores specific to acute PE to optimally target bleeding-prevention strategies.