Anticoagulants combined with antiplatelet agents after ACS (dual/triple therapy)
PCI during index hospitalization
About this score
The ORACUL score was developed to stratify bleeding risk in patients presenting with acute coronary syndrome, including those managed with dual or triple antithrombotic therapy (antiplatelet agents combined with anticoagulants). It was derived and validated in the ORACUL II registry led by Panchenko EP and Kropacheva ES, with external validation in the RECORD-3 registry.
The score combines demographic, laboratory, hemodynamic and treatment-related variables at the time of the index hospitalization for ACS. Points are summed across seven variables to produce a total score, which is then mapped to one of four bleeding risk categories.
The tool is intended to support decisions on the intensity and duration of antithrombotic therapy after ACS, particularly when balancing ischemic and bleeding risk in patients requiring combined antiplatelet and anticoagulant treatment.
When to use
Estimating bleeding risk in patients hospitalized with STEMI or NSTEMI
Assessing bleeding risk before starting or continuing dual or triple antithrombotic therapy after ACS
Supporting decisions on duration and intensity of antithrombotic treatment in ACS patients with additional risk factors (renal impairment, anemia, prior ulcer disease)
Parameters in detail
Age
Patient age at the time of the index ACS hospitalization. Risk increases with age.
Hemoglobin on admission
Hemoglobin concentration measured at admission. Lower hemoglobin adds more points.
Killip class of heart failure
Killip classification of heart failure severity on admission. Killip class II-IV (evidence of heart failure) adds points compared with Killip I.
Creatinine clearance
Creatinine clearance, reflecting renal function. Lower clearance adds more points.
History of gastric or duodenal ulcer disease
History of peptic ulcer disease of the stomach or duodenum, a known risk factor for gastrointestinal bleeding.
Anticoagulants combined with antiplatelet agents after ACS (dual/triple therapy)
Use of an anticoagulant in combination with one or more antiplatelet agents after ACS (dual or triple antithrombotic therapy), which increases bleeding risk compared with antiplatelet therapy alone.
PCI during index hospitalization
Percutaneous coronary intervention performed during the index hospitalization for the current ACS episode.
Clinical example
Case
A 70-year-old man is admitted with NSTEMI. Hemoglobin on admission is 110 g/L, he presents in Killip class I, and creatinine clearance is 55 mL/min. He has no history of peptic ulcer disease, is not being started on combined anticoagulant plus antiplatelet therapy, and did not undergo PCI during this admission.
Calculation
Age 66-75 years: 16 points. Hemoglobin 100-125 g/L: 48 points. Killip I: 0 points. Creatinine clearance < 60 mL/min: 12 points. No ulcer history, no dual/triple antithrombotic therapy, no PCI: 0 additional points. Total score = 16 + 48 + 0 + 12 = 76 points.
Interpretation and management
A score of 76 falls in the 68-107 range, corresponding to moderate bleeding risk, with an estimated bleeding probability of approximately 2.8%.
Limitations and cautions
Derived and validated primarily in Russian ACS cohorts (ORACUL II, RECORD-3); performance in other populations has not been established to the same extent.
Does not replace clinical judgment or established international bleeding risk tools (e.g., CRUSADE, ACUITY, PRECISE-DAPT) when managing antithrombotic therapy after ACS.
Point values for individual binary risk factors in this tool were not specified in the source data used to build this calculator.
Frequently asked questions
What does the ORACUL score assess?
It estimates the probability of bleeding in patients hospitalized with acute coronary syndrome, including those on dual or triple antithrombotic therapy.
How was the ORACUL score developed?
It was derived from the ORACUL II registry by Panchenko EP, Kropacheva ES and colleagues, with external validation in the RECORD-3 registry.
Can the ORACUL score be used for both STEMI and NSTEMI?
Yes, it was developed for patients with acute coronary syndrome, encompassing both ST-elevation and non-ST-elevation presentations.
How should the ORACUL score inform treatment decisions?
Higher scores indicate higher bleeding risk and should prompt closer consideration of the intensity and duration of antithrombotic therapy, alongside assessment of ischemic risk.
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Aleksandr A. Aulov
Physician, internal medicine, Sechenov School — independent medical education platform.
Calculators are compiled from the original publications and current clinical guidelines. Interpretation thresholds follow the source study unless stated otherwise.
This calculator is intended for healthcare professionals. Do not use it for self-diagnosis or self-treatment. Management decisions are made by the treating clinician based on the full clinical picture of the individual patient.
Last clinical review: April 28, 2026 ·
Author: Aleksandr A. Aulov,
MD, internal medicine ·
Primary source: Кропачева Е.С., Панченко Е.П. и соавт. Регистр ОРАКУЛ II; внешняя валидация — регистр РЕКОРД-3