Calc Function

    • Calcs that help predict probability of a diseaseDiagnosis
    • Subcategory of 'Diagnosis' designed to be very sensitiveRule Out
    • Disease is diagnosed: prognosticate to guide treatmentPrognosis
    • Numerical inputs and outputsFormula
    • Med treatment and moreTreatment
    • Suggested protocolsAlgorithm

    Disease

    Select...

    Specialty

    Select...

    Chief Complaint

    Select...

    Organ System

    Select...

    Patent Pending

    HEMORR₂HAGES Score for Major Bleeding Risk

    Quantifies risk of hemorrhage in elderly patients with AFib.
    Favorite

    INSTRUCTIONS

    The HEMORR2HAGES Score was developed using ICD-9 data; while we are actively reaching out to its study authors, the terms included in the score are not defined in the study.
    When to Use
    Pearls/Pitfalls
    Why Use

    Consider using the HEMORR2HAGES score to stratify patients’ risk for bleeding after anticoagulation for atrial fibrillation in conjunction with situation specific risks/benefits.

    The HEMORR2HAGES score was developed to quantify the risk of hemorrhage in patients with atrial fibrillation on anticoagulation and to aid in the management of antithrombotic therapy.

    • Combined hemorrhage risk factors from three previously existing clinical prediction rules to form the HEMORR2HAGES mnemonic.
    • Validated the score by retrospectively applying it to a cohort of patients from the National Registry of Atrial Fibrillation database.
    • Scoring system consists of eleven criteria, one of which (history of prior bleeding) is worth 2 points, while the other ten are worth 1 point each.
    • For the basis of comparison to other bleeding risk schemes, patients with a score of 0 or 1 were classified as low-risk, 2 or 3 intermediate-risk, ≥4 high-risk.
    • Study found that the number of bleeds per 100 patient-years of warfarin increased as their HEMORR2HAGES score increased.
    • For patients on warfarin, study found that HEMORR2HAGES was more discriminatory compared to the other schemes.

    Points to keep in mind:

    • Degree of hemorrhage was not examined in the study; all study patients with ICD-9 codes for active hemorrhage in any location were included.
    • The genetic risk factor was included in their score, but not actually tested in their cohort of patients.
    • There were variable definitions of hepatic or renal disease, thrombocytopenia depending on the state in which the patient lived.
    • All data was obtained retrospectively, via chart review and ICD-9 codes. Events occurring outside of the hospital or coded incorrectly were not included.
    • Anemia, malignancy and uncontrolled hypertension were included in a patient’s score if they were entered in as ICD-9 diagnoses, regardless if they were clinically important or not (e.g. distant history of cancer which has been in complete remission would still count as malignancy by ICD-9).
    • Excessive fall risk was determine by chart review for “high risk of falling, dementia, Parkinson's disease, or psychiatric disease.”
    • Study also examined ASA usage, but does not present specific data on the risk of hemorrhage on ASA with different HEMORR2HAGES scores.
    • There was no comparison to more recently derived bleeding risk scores such as ATRIA or HAS-BLED.

    A subsequent systemic review and meta-analysis comparing the performance of HAS-BLED, ATRIA and HEMORR2HAGES recommended HAS-BLED for the assessment of atrial fibrillation patients’ major bleeding risk. The analysis found that HEMORR2HAGES had a higher diagnostic accuracy, but considered it difficult to use due to its complexity.

    Combines components from several other previously validated bleeding risk scores into one.

    No
    0
    Yes
    +1
    No
    0
    Yes
    +1
    No
    0
    Yes
    +1
    No
    0
    Yes
    +1
    No
    0
    Yes
    +1
    No
    0
    Yes
    +2
    No
    0
    Yes
    +1
    No
    0
    Yes
    +1
    No
    0
    Yes
    +1
    No
    0
    Yes
    +1
    No
    0
    Yes
    +1

    Result:

    Please fill out required fields.

    Next Steps
    Evidence
    Creator Insights

    Critical Actions

    • Risks and benefits of anticoagulation should be carefully considered in ALL patients prior to initiating therapy.
    • Other risk stratification scores such as HAS-BLED or ATRIA should also be taken into consideration prior to starting anticoagulation.
    • Alternative options should often be considered in patients with high-risk of major bleeding events in need of anticoagulation.
    Content Contributors
    About the Creator
    Dr. Brian Gage
    Are you Dr. Brian Gage?
    Content Contributors