A comparison of the clinical impact of bleeding measured by two different classifications among patients with acute coronary syndromes

Sunil V. Rao, Kristi O'Grady, Karen S. Pieper, Christopher B. Granger, L. Kristin Newby, Kenneth W. Mahaffey, David J. Moliterno, A. Michael Lincoff, Paul W. Armstrong, Frans Van De Werf, Robert M. Califf, Robert A. Harrington

Research output: Contribution to journalArticlepeer-review

290 Scopus citations


OBJECTIVES: The goal of this study was to determine the association between Thrombolysis In Myocardial Infarction (TIMI) and Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) bleeding and clinical outcomes. BACKGROUND: There are limited data on the relative utility of either scale at predicting clinical outcomes in patients with non-ST-segment elevation acute coronary syndromes (ACS). METHODS: Pooled data from two randomized trials of patients with ACS (n = 15,454) were analyzed to determine the association between TIMI and GUSTO bleeding and 30-day and 6-month death/myocardial infarction (MI) using Cox proportional hazards modeling that included bleeding as a time-dependent covariate. RESULTS: There was a stepwise increase in the adjusted hazard of 30-day death/MI with worsening GUSTO bleeding (hazard ratio [95% confidence interval], GUSTO mild 1.20 [1.05 to 1.37]; moderate 3.28 [2.88 to 3.73]; severe 5.57 [4.33 to 7.17]), and an increased risk with all three levels of TIMI bleeding (TIMI minimal 1.84 [1.63 to 2.08]; TIMI minor 1.64 [1.31 to 2.04]; major 1.45 [1.23 to 1.70]). When both bleeding scales were included in the same model, the risk with GUSTO bleeding persisted; however, the association between TIMI bleeding and outcome was no longer significant. CONCLUSIONS: Both scales identify ACS patients with bleeding complications at risk for adverse outcomes. In a model that included both definitions, the risk with GUSTO bleeding persisted while the risk with TIMI bleeding did not. This suggests that bleeding assessed with clinical criteria is more important than that assessed by laboratory criteria in terms of outcomes. Future clinical trials should consider using a combination of the GUSTO bleeding scale and the need for transfusion to assess bleeding complications.

Original languageEnglish
Pages (from-to)809-816
Number of pages8
JournalJournal of the American College of Cardiology
Issue number4
StatePublished - Feb 21 2006

Bibliographical note

Funding Information:
This analysis was supported by the Duke Clinical Research Institute, Durham, North Carolina.

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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