PTAR-A-Novel-Marker-for-Predicting-Upper-Gastrointestinal-Bleeding-Severity.pptx

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1. PTAR: A Novel Marker for Predicting Upper Gastrointestinal Bleeding Severity Upper gastrointestinal bleeding (UGIB) is a life-threatening emergency requiring rapid assessment and intervention. Early risk stratification is crucial for determining effective management strategies. This presentation introduces the International Normalized Ratio-to-Albumin Ratio (PTAR) as a novel marker for predicting UGIB severity and compares its performance with existing prognostic tools. PT by PLS DO NOT CHANGE THIS

2. The Impact of Upper Gastrointestinal Bleeding $1B+ Annual Cost Direct medical costs in the United States alone 26.4% Variceal Bleeding Percentage of patients with variceal bleeding in the study 36.2% Ulcer Bleeding Percentage of patients with ulcer bleeding in the study 37.4% Other Causes Including Mallory-Weiss tear, gastric cancer, angiodysplasia UGIB represents a significant healthcare burden, requiring frequent hospitalizations and carrying substantial morbidity and mortality risks. Early and accurate risk assessment is essential for optimizing patient outcomes and resource allocation.

3. Current Prognostic Tools for UGIB Glasgow-Blatchford Score (GBS) Validated as an accurate tool for assessing early UGIB severity. Includes heart rate, systolic blood pressure, blood urea nitrogen, and hemoglobin levels. One of the most commonly used assessment tools. Rockall Score Includes both pre- and post-endoscopic components. Has high predictive capability for mortality but requires several components, making it challenging to use in emergency settings. AIMS65 Score Good predictor for hospitalization length and in-hospital mortality. Calculated using albumin level, INR, mental status, systolic blood pressure, and age. Simple but effective, especially in patients with cirrhosis.

4. Limitations of Current Prognostic Tools 1 Complex Variables Many current assessment tools require multiple clinical and laboratory variables, making them difficult to calculate quickly in emergency settings when rapid decisions are crucial. 2 Need for Endoscopy Some scoring systems like the complete Rockall score require endoscopy results, which delays risk stratification and immediate decision-making in the emergency department. 3 Varying Performance The predictive performance of existing tools can vary depending on patient populations and specific outcomes (mortality, rebleeding, need for intervention), limiting their universal applicability. 4 Resource Intensity Comprehensive assessment using established scores may require resources that aren't readily available in all emergency settings, particularly in resource-limited environments.

5. Introducing PTAR: A Novel Marker Definition PTAR (Prothrombin Time-International Normalized Ratio-to-Albumin Ratio) is an objective liver function score model that divides the PT-INR value by the albumin value. Previous Applications PTAR has been used for risk stratification in hepatic cellular carcinoma and sepsis, showing strong correlations with outcomes in liver-related conditions. Liver Function Connection Decreased liver function is associated with higher mortality and morbidity in UGIB patients, making liver function assessment crucial in the emergency department. The simplicity of PTAR calculation makes it particularly attractive for emergency settings where rapid assessment is needed. By combining measures of coagulation (PT-INR) and liver synthetic function (albumin), PTAR provides a comprehensive yet straightforward evaluation of a patient's condition.

6. Study Design and Methods Study Design Retrospective observational study performed at the emergency department of a tertiary university hospital accommodating 43,000 patients annually, approximately 250 of whom present with UGIB. Patient Selection 520 patients who visited the ED with UGIB as the chief presentation between January 2019 and December 2020 were evaluated. After exclusions, 519 patients were included in the final analysis. Data Collection Data collected included demographics, vital signs, laboratory values, comorbidities, and clinical outcomes. PT-INR and albumin were measured within 1 hour of ED arrival to calculate PTAR. Outcome Measures The primary endpoints were ICU admission and mortality. The study also calculated and compared the predictive performance of PTAR with traditional scoring systems (GBS, Rockall score, AIMS65).

7. Patient Characteristics Characteristic All patients (n=519) Non-ICU (n=356) ICU (n=163) p-Value Age (years) 63.86 ± 17.04 63.84 ± 18.31 63.91 ± 13.93 0.533 Male, n (%) 343 (66.1%) 216 (60.7%) 127 (77.9%) ≤0.001 SBP, mmHg 116 (53-254) 121 (53-222) 106 (53-254) ≤0.001 Hemoglobin, g/dL 9.6 (2.9-18.1) 10.4 (3.6-17.5) 8.2 (2.9-18.1) ≤0.001 PT-INR 1.11 (0.75-6.63) 1.08 (0.75-6.63) 1.26 (0.86-5.49) ≤0.001 Albumin, g/dL 3.5 (1.1-5.8) 3.7 (1.7-5.8) 3.1 (1.1-5.6) ≤0.001 The study population included 519 patients with UGIB: 137 (26.4%) with variceal bleeding, 188 (36.2%) with ulcer bleeding, and 194 (37.4%) with other causes. There were significant differences between ICU and non-ICU patients in multiple parameters, particularly those related to bleeding severity and liver function.

8. Comparison: ICU vs. Non-ICU Patients Vital Signs ICU patients had significantly lower systolic blood pressure (106 mmHg vs. 121 mmHg, p≤0.001), indicating more severe hemodynamic compromise. 1 Hematologic Measures ICU patients showed lower hemoglobin (8.2 g/dL vs. 10.4 g/dL, p≤0.001) and platelet count (164,000 vs. 214,000, p≤0.001), reflecting greater blood loss and potential coagulopathy. 2 Renal Function Higher blood urea nitrogen (33.9 mg/dL vs. 30.1 mg/dL, p≤0.001) and creatinine (1.18 mg/dL vs. 0.96 mg/dL, p≤0.001) in ICU patients suggested compromised renal function. 3 Liver Function ICU patients had higher PT-INR (1.26 vs. 1.08, p≤0.001) and lower albumin levels (3.1 g/dL vs. 3.7 g/dL, p≤0.001), indicating more significant liver dysfunction. 4 The comparison reveals that ICU patients presented with more severe clinical and laboratory abnormalities across multiple organ systems, particularly related to cardiovascular stability, hematologic parameters, and liver function.

9. Comparison: Survivors vs. Non-Survivors Hemodynamic Status Non-survivors showed significantly lower systolic blood pressure (100 mmHg vs. 117 mmHg, p≤0.001), indicating more severe shock and cardiovascular compromise. Blood Loss Severity The mortality group had lower hemoglobin levels (7.7 g/dL vs. 9.6 g/dL, p≤0.001), suggesting more severe bleeding and potentially greater transfusion requirements. Organ Dysfunction Non-survivors demonstrated higher creatinine (1.5 mg/dL vs. 0.98 mg/dL, p≤0.001), higher PT-INR (1.50 vs. 1.10, p≤0.001), and lower albumin (2.9 g/dL vs. 3.6 g/dL, p≤0.001). Comorbidity Burden All patients in the mortality group (100%) had comorbidities compared to 85.7% in the survivor group (p=0.032), highlighting the impact of pre-existing conditions on outcomes.

10. Influencing Factors of ICU Admission After adjusting for confounding factors (age, sex, systolic blood pressure, comorbidities, hemoglobin, and platelet count), PTAR emerged as the strongest predictor of ICU admission with an adjusted odds ratio of 8.376 (95% CI: 2.722-25.774). This significantly outperformed traditional scoring systems, with AIMS65 having the next highest adjusted odds ratio at 1.699 (95% CI: 1.318-2.192).

11. Influencing Factors of Mortality PTAR Impact PTAR demonstrated the highest adjusted odds ratio for mortality at 27.846 (95% CI: 8.701-89.116), making it the strongest predictor of fatal outcomes among all evaluated metrics. AIMS65 Performance The AIMS65 score showed the second highest adjusted odds ratio at 2.154 (95% CI: 1.473-3.149), confirming its established utility in predicting mortality. Pre-Endoscopy Rockall This score had moderate predictive value with an adjusted odds ratio of 1.647 (95% CI: 1.048-2.589), supporting its continued use in initial assessment. GBS Limitations After adjustment, the Glasgow-Blatchford Score did not show statistical significance for mortality prediction, highlighting its limitations in this specific outcome.

12. Predictive Performance for ICU Admission 1 PTAR (AUC: 0.720) With a cutoff value >0.320, PTAR showed 74.23% sensitivity and 58.43% specificity for predicting ICU admission. This represents the highest area under the curve among all evaluated methods, indicating superior discriminatory ability. 2 Complete Rockall Score (AUC: 0.670) Using a cutoff >5, this score achieved 76.69% sensitivity and 49.44% specificity. Despite requiring endoscopy results, it showed only moderate predictive performance. 3 AIMS65 (AUC: 0.656) With a cutoff >1, AIMS65 demonstrated 51.53% sensitivity and 75.56% specificity, offering good specificity but limited sensitivity for ICU admission prediction. 4 GBS (AUC: 0.653) Using a cutoff >6, GBS showed high sensitivity (84.66%) but poor specificity (41.01%), resulting in many false positives when predicting ICU admission.

13. Predictive Performance for Mortality 1 PTAR (AUC: 0.816) Highest predictive accuracy 2 AIMS65 (AUC: 0.764) Strong mortality prediction 3 Complete Rockall (AUC: 0.741) Good but requires endoscopy 4 Pre-endoscopy Rockall (AUC: 0.736) Reliable early assessment 5 GBS (AUC: 0.657) Limited mortality prediction For mortality prediction, PTAR demonstrated superior performance with a cutoff value >0.358, yielding 85.71% sensitivity and 64.88% specificity. This significantly outperformed all traditional scoring methods, including AIMS65 which showed the second-best performance. These findings suggest PTAR offers clinicians a more accurate tool for identifying high-mortality-risk patients early in their presentation.

14. Clinical Applications of PTAR Early Risk Stratification PTAR can be calculated immediately upon ED arrival to identify high-risk patients requiring intensive monitoring and intervention. 1 Resource Allocation Using PTAR helps optimize resource utilization by identifying patients truly requiring ICU-level care versus those who can be safely managed in regular wards. 2 Treatment Intensity Decisions High PTAR values may guide decisions regarding aggressive resuscitation, transfusion thresholds, and timing of endoscopic intervention. 3 Prognostic Communication PTAR provides objective data for discussions with patients and families regarding expected outcomes and treatment plans. 4 Quality Improvement Tracking outcomes based on PTAR values can help institutions refine their UGIB management protocols and improve care quality. 5 The simplicity of PTAR calculation using two readily available laboratory parameters (PT-INR and albumin) makes it particularly valuable in emergency settings where rapid decision-making is crucial. Its strong predictive performance for both ICU admission and mortality supports its integration into clinical practice guidelines for UGIB management.

15. Conclusions and Future Directions Simple Yet Powerful PTAR represents a simple calculation using two readily available laboratory parameters (PT-INR and albumin) that outperforms more complex scoring systems in predicting UGIB outcomes. Early Application Unlike scoring systems requiring endoscopy or multiple clinical variables, PTAR can be calculated immediately upon ED arrival, enabling rapid risk stratification when it matters most. Future Research Prospective validation studies across diverse patient populations and healthcare settings are needed, as are investigations into whether PTAR-guided interventions can improve patient outcomes. The PTAR measured in the emergency department is an independent factor strongly associated with ICU admission and mortality in patients with UGIB. Its superior predictive capability compared to conventional scoring methods supports its use as a risk stratification marker in early emergency settings. Further research should explore its applicability across different patient populations and whether PTAR-guided management strategies can improve outcomes.