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    HAS-BLED Score for Major Bleeding Risk

    Estimates risk of major bleeding for patients on anticoagulation to assess risk-benefit in atrial fibrillation care.
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    • Consider using the HAS-BLED Score as a tool to potentially guide the decision to start 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 CHADS2 or CHA2DS2-VASc to determine if the benefit of anticoagulation outweighs the risk.

    Clinical factors that contribute to stroke risk and support anticoagulation in patients with atrial fibrillation are frequently risk factors for bleeding as well. 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 5,333 ambulatory and hospitalized patients with AF from both academic and non-academic hospitals in 35 member countries of the European Society for Cardiology.

    • Patients were followed up at one year to determine survival and major adverse cardiovascular events, such as major bleeding.
    • Major bleeding defined as any bleeding requiring hospitalization, and/or causing a decrease in hemoglobin level > 2 g/L, and/or requiring blood transfusion that was not hemorrhagic stroke.
    • Researchers performed a retrospective, univariate analysis to find potential bleeding risk factors when comparing the groups with and without 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 risk factors, with an overall major bleed rate of 1.5%.

    Points to keep in mind:

    • Study only provides risk percentages for given risk factor, does not categorize scores into low/medium/high risk
    • HAS-BLED score, in the form that it was developed originally, still needs to be externally validated
    • A modified version of the HAS-BLED score has been validated in a Japanese population. This study used different standards for hypertension and labile INR and did not include alcohol consumption.
    • A study comparing HEMORR2HAGES, ATRIA and HAS-BLED showed superior performance of the HAS-BLED score compared to the other two.

    The HAS-BLED Score can guide the decision to start anticoagulation in patients with atrial fibrillation.

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    Patient specific risks and benefits of anticoagulation must be carefully weighed in all patients who are potential candidates for long-term anticoagulation therapy.

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    About the Creator
    Dr. Ron Pisters
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