Systematic review: the presenting international normalised ratio (INR) as a predictor of outcome in patients with upper nonvariceal gastrointestinal bleeding

Background The prognostic value of an elevated international normalised ratio (INR) as part of initial risk stratification in nonvariceal upper gastrointestinal bleeding (NVUGIB) remains poorly characterised. Aim To assess the usefulness of the initial INR in patients with NVUGIB. Method After a systematic review, we included the presenting INR and other validated prognosticators in multivariable models predicting rebleeding and mortality. Data are reported as odd ratios and 95% confidence intervals. Results Only two of 769 candidate studies were useful, but reported disparate, highly selected NVUGIB patients with varying threshold initial INR values, yielding conflicting results on predictive ability. The RUGBE cohort included 1869 patients (mean age 66.3 +/- 16.8, 38.1% female) with a mean presenting INR of 1.5 +/- 1.7. 462 (24.7%) patients had an elevated INR (INR > 2.5 in 7.6%). INR did not add to the prediction of rebleeding. An INR > 1.5, in contradistinction, significantly predicted mortality (OR: 1.96; 95% CI: 1.13-3.41). Conclusions An elevated INR at initial presentation does not predict rebleeding in NVUGIB. A value 1.5 or greater, however, is associated with increased patient mortality after adjustment for validated prognosticators. The INR appears most useful as proxy of co-morbid burden at the time of initial assessment in NVUGIB.