RIETE Score for Risk of Hemorrhage in Pulmonary Embolism Treatment

Why Use

The RIETE score is based on a very large cohort of patients and, if validated, has a significant difference in outcomes between the low and high risk groups, making it a potentially powerful tool to guide the decision to anticoagulate.

When to Use

Consider using the RIETE score to stratify patients’ risk for bleeding after anti-coagulation for DVT/PE in conjunction with situation specific risks/benefits.

Formula

Pearls / Pitfalls

The RIETE registry developed a clinical score to stratify a patient’s risk of major bleeding with anticoagulation for DVT or PE. Included all patients with symptomatic acute DVT or PE diagnosed by CTV or US for DVT and pulmonary angiography, lung scintigraphy or helical CT for PE Scoring system consisted of 6 criteria, 1 of which was worth 2 points, 2 worth 1.5 points each, and 3 worth 1 point each The study used 0 points to define low risk for major bleeding events (0.1% risk of bleeding), 1-4 points for intermediate risk (2.8% risk), and >4 points for high risk (6.2% risk) Major bleeding was defined as overt bleeding plus one of the following: Required transfusion of 2+ units of blood, Retroperitoneal, spinal or intracranial, OR Fatal Points to keep in mind: Study used same population for derivation and validation cohorts Did not distinguish between different types of anticoagulation Anemia was never defined Score has not been externally validated. The only validation study to date utilized the same RIETE database and used a different endpoint. A subsequent risk score has been developed by the ATRIA group which also used similar criteria in their score to determine risk of bleeding after anti-coagulation with warfarin for atrial fibrillation. They also had a similar overall bleeding rate as the RIETE group.

Critical Actions

Risks and benefits of anti-coagulation should be carefully considered in ALL patients prior to initiating therapy Alternative options should often be considered in patients with high-risk of major bleeding events in need of anti-coagulation

More Information

Risk Factor Point Value Recent Major Bleeding 2 Cr >1.2 mg/dL 1.5 Anemia 1.5 Cancer 1 Clinically-overt PE 1 Age >75 1