HAS-BLED Score for Major Bleeding Risk
Why Use
The HAS-BLED Score can assist in the shared decision-making discussion regarding anticoagulation in patients with atrial fibrillation.
When to Use
Consider using the HAS-BLED Score as a reference tool to assist in the shared decision-making discussion regarding anticoagulation in patients with atrial fibrillation. Consider using the HAS-BLED Score instead of, or in conjunction with, other bleeding risk scores such as HEMORR₂HAGES and ATRIA to determine risk of major bleeding in a patient with atrial fibrillation. Consider comparing the risk for major bleeding as calculated by the HAS-BLED Score to the risk for thromboembolic events by the CHA₂DS₂-VASc to determine if the benefit of anticoagulation outweighs the risk.
Formula
Pearls / Pitfalls
The HAS-BLED Score was developed as a practical risk score to estimate the 1-year risk for major bleeding in patients with atrial fibrillation. Study included 3456 ambulatory and hospitalized patients with AF and one-year follow-up status regarding major bleeding, and without mitral valve stenosis or valvular surgery. Patients were followed up at one year to determine survival and major adverse cardiovascular events, such as major bleeding. Major bleeding was defined as intracranial hemorrhage, bleeding requiring hospitalization, bleeding with hemoglobin decrease >2 g/L, or bleeding requiring transfusion. Researchers performed univariable analysis to find potential bleeding risk factors associated with major bleeding at 1 year follow-up. Developed HAS-BLED score based on results of their analysis as well as known significant risk factors for major bleeding. Results showed that the annual bleeding rate increased with increasing scores. Points to keep in mind: Despite its popularity, neither the European nor the American guidelines recommend any specific risk score for predicting bleeding events in patients with AF. The derivation study was based on a cohort in which only around 2/3 were on any antithrombotic therapy. The score has since been validated extensively. Clinical factors that contribute to stroke risk and support anticoagulation in patients with atrial fibrillation are frequently risk factors for bleeding as well. There may be superior predictive scores for bleeding events in patients taking direct oral anticoagulants, e.g. the DOAC Score . Use this score with caution in patients with conditions that are associated with elevated bleeding risks, including but not limited to chronic kidney disease and cancer – this score has been shown to perform poorly in both of these conditions.
Critical Actions
Patient specific risks and benefits of anticoagulation must be carefully weighed in all patients who are potential candidates for long-term anticoagulation therapy.
More Information
HAS-BLED Score Risk group Risk of major bleeding** Bleeds per 100 patient-years*** Recommendation 0 Low 0.9% 1.13 Anticoagulation should be considered 1 3.4% 1.02 2 Moderate 4.1% 1.88 Anticoagulation can be considered 3 High 5.8% 3.72 Alternatives to anticoagulation should be considered 4 8.9% 8.70 5 9.1% 12.50 >5* Very high – – *Scores greater than 5 were too rare to determine risk, but are likely over 10%. **Risk figures from Lip 2011 . ***Risk figures from Pisters 2010 .