A risk score to predict silent myocardial ischemia in patients with coronary artery disease under aspirin therapy presenting with upper gastrointestinal hemorrhage

Background

Silent myocardial ischemia (SMI) is a relatively common complication in patients with coronary artery disease (CAD) under aspirin therapy presenting with upper gastrointestinal hemorrhage (UGIH).

Aim

This study was conducted to develop and prospectively validate a risk prediction score to identify SMI in patients undergoing aspirin therapy for CAD presenting with UGIH in the emergency department (ED).

Methods

This was a 2-phase noninterventional study. In the derivation phase, adults with CAD under aspirin therapy (100 mg once daily) presenting to the ED with UGIH were retrospectively recruited. By multiple logistic regression analysis, we derived a risk score from 224 patients that predicts the patients' risk of SMI. In the validation phase, we prospectively validated this score using receiver operating characteristic curves with data from 110 patients. We also developed a fast-track screening procedure from this score.

Results

There were 56 patients (25.0%) and 29 patients (26.4%) with SMI in the derivation and validation sets, respectively. Independent multivariate predictors of SMI were age of older than 75 years, severity of CAD, systolic blood pressure of less than 110 mm Hg, diastolic blood pressure of less than 85 mm Hg, hematocrit of less than 30%, and blood urea nitrogen–creatinine ratio of more than 30. The area under receiver operating characteristic curve for the rule was 0.93 in the derivation set and 0.96 in the validation set. At the cutoff value of 5 points or higher, the sensitivity and specificity of the fast-track screening procedure for SMI were 96.6% and 86.4%, respectively. The positive and negative predictive values were 71.8% and 98.6%, respectively.

Conclusions

This simple risk prediction score is easily calculated and is based on rapidly available clinical and laboratory data in the ED. It can be used to stratify patients undergoing aspirin therapy for CAD presenting with UGIH by risk of SMI.