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Background Bleeding prediction scores may help to guide acute management of patients with pulmonary embolism (PE). However, existing scoring systems have not been validated for in-hospital assessment. We aimed to compare 6 available bleeding scores, in a real-life cohort for the prediction of major in-hospital bleeding. Methods We recorded in-hospital characteristics of 2,754 PE patients included in a prospective observational multicenter cohort study contributing 18,028 person-days of follow-up. We assessed the VTE-BLEED, RIETE, ORBIT, HEMORRA2HAGES, ATRIA, and HAS-BLED scores at baseline. ISTH-defined bleeding events were independently adjudicated. The accuracy of the scores for the prediction of in-hospital bleeding was evaluated and compared. Results We observed 82 first in-hospital major bleeding events (3.0% (95% CI, 2.4–3.7)). Overall, the predictive power of bleeding scores was poor, with a C index ranging from 0.57 to 0.69 (Figure 1). The RIETE score had the numerically highest model fit and best discriminatory capacity, but without reaching statistical significance versus the ORBIT, HEMORR2HAGES, and ATRIA scores. The VTE-BLEED and HAS-BLED scores had significantly lower C indices, integrated discrimination improvement, and net reclassification improvement compared to the four others. Conclusion Currently available scoring systems have insufficient accuracy for the prediction of in-hospital major bleeding in patients with acute PE. The development of acute-PE-specific risk scores is needed to optimally target patients that warrant bleeding-prevention strategies. Funding Acknowledgement Type of funding sources: None. Figure 1

Available bleeding scoring systems poorly predict major bleeding in the acute phase of pulmonary embolism