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Three Part Question

In [an elderly carcinoma patient with risk of bleeding increased by multiple co-morbidities presenting in emergency room] with [Atrial Fibrillation] [Is there any recommended Clinical Scoring System for evaluation of bleeding risk]?

Clinical Scenario

59 year old male, presented to the emergency room with dyspnea and angina at rest. His past history was significant for Esophageal cancer on chemo-radiation, Ischemic stroke (left ACA territory – month prior to current presentation), Chronic Kidney disease, hypertension and diabetes mellitus.
On examination, he had a heart rate of 192/minute and not in shock; ECG showed Atrial Fibrillation. His Blood Urea was 68 g/dl and Serum Creatinine was 2.3 mg/dl. His Troponin I was positive. Metaprolol was given at out emergency room which brought the heart rate under control.
As the heart rate improved, the ECG changes were suggestive of Non-ST Elevation Myocardial Infarction. ECHO showed severe LV dysfunction with Ejection Fraction of 33%.
Issues
The dilemma of administering an anticoagulant as the patient had stroke recently and what is the anticoagulant of choice?
In this patient with abnormal renal function enoxaparin sodium is contraindicated. Warfarin is also risky as this patient had cerebrovascular disease, hypertension, Chronic Kidney disease and malignancy on active treatment. Generally, anticoagulant is contraindicated in inaccessible ulceration (in this case - esophageal carcinoma).

Search Strategy

(Cancer patient with Atrial Fibrillation) and (Clinical Scoring System for evaluation of Bleeding Risk) in PUBMED interface on the world wide web, was searched using the terms above. Limit was set to human species and English Language. No other limits were set. Search date - 06/06/16.
We used the following keywords in pubmed search:

Cancer patient with Atrial Fibrillation Bleeding Risk

Cancer atrial fibrillation bleeding score

Search Outcome

A total of 23 articles were retrieved. Only one article was relevant. In addition we did the “related articles search” for that single relevant article, but found no further articles of relevance.

Each of the above keywords gave variable number of results from 13-23. Only one literature was relevant clinically in human population.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Christos Voukalis, Gregory Y.H. Lip, Eduard Shantsila January 2016 United Kingdom	Literature Review	Various bleeding risk scores have been described but only four HAEMORR2AGES, HAS-BLED, ATRIA and ORBIT were developed and verified in AF populations. The HAS-BLED score demonstrated good discriminatory performance for “any clinically relevant bleeding” in anticoagulated patients with Atrial Fibrillation (AF). It also performs well in predicting bleeding events compared with older bleeding scores and the ATRIA score. Other scores such as ATRIA or ORBIT may falsely categorise some patients as “low risk’ with no action needed whilst the HAS-BLED score would flag up those subjects, particularly if labile INRs are evident. Additionally, the simple HAS-BLED score was highly predictive of bleeding events in patients manages with non-vitamin K oral anticoagulants, patients on triple antithrombotic therapy post PCI (i.e., dual anti-platelets therapy and warfarin) and during bridging of chronic oral anticoagulants with unfractionated or low molecular weight heparin prior to surgery.	Among the scoring system for bleeding risk HAEMORR2AGES is the only system incorporating previous history of malignancy. HAEMORR2AGES is complex and HAS-BLED score is simple to use in emergency scenario. HAS-BLED score does not incorporate cancer in it’s scoring criteria whereas HAEMORR2AGES does. There is no randomized study comparing HAS-BLED score and HAEMORR2AGES score, but HAS-BLED score has been recommended based on meta-analysis and systematic reviews for it’s simplicity and good discriminatory performance. Specific scoring system need to be developed for cancer patients.	HAS-BLED score demonstrated good discriminatory performance in cancer patients.	This is not a Randomized Control Study.

Comment(s)

This literature is a extensive review of all relevant papers and useful guide in Emergency room.

Clinical Bottom Line

HAS-BLED score can be used for emergencies in oncology patient till a more suitable one is developed.

References

1. Christos Voukalis Emerging Tools for Stroke Prevention in Atrial Fibrillation EBioMedicine 2016 Jan 15;4:26-39