HEMORR₂HAGES Score for Major Bleeding Risk
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.