HAS-BLED

HAS-BLED is a scoring system developed to assess 1-year risk of major bleeding in people taking anticoagulants for atrial fibrillation (AF). It was developed in 2010 with data from 3,978 people in the Euro Heart Survey.[1] Major bleeding is defined as being intracranial bleedings, hospitalization, hemoglobin decrease > 2 g/dL, and/or transfusion.[1]

HAS-BLED score
Purposerisk of major bleeding

Definition

HAS-BLED is a medical tool used to calculate the one-year risk of major bleeding for people on blood thinning drugs for atrial fibrillation (AF).[2] It is used with the CHA2DS2-VASc score.[3]

Use
Condition Points
 H   Hypertension: (uncontrolled, >160 mmHg systolic)
1
 A  Abnormal renal function: Dialysis, transplant, Cr >2.26 mg/dL or >200 µmol/L

Abnormal liver function: Cirrhosis or Bilirubin >2x Normal or AST/ALT/AP >3x Normal
1

1
 S  Stroke: Prior history of stroke
1
 B  Bleeding: Prior Major Bleeding or Predisposition to Bleeding
1
 L  Labile INR: (Unstable/high INR), Time in Therapeutic Range < 60%
1
 E  Elderly: Age > 65 years
1
 D  Prior Alcohol or Drug Usage History (≥ 8 drinks/week)

Medication Usage Predisposing to Bleeding: (Antiplatelet agents, NSAIDs)
1

1

A calculated HAS-BLED score is between 0 and 9 and based on seven parameters with a weighted value of 0-2.

The HAS-BLED mnemonic stands for:

  • Hypertension
  • Abnormal renal and liver function
  • Stroke
  • Bleeding
  • Labile INR
  • Elderly
  • Drugs or alcohol

A study comparing HEMORR2HAGES, ATRIA and HAS-BLED showed superior performance of the HAS-BLED score compared to the other two.[4] Mixed evidence exist on the comparison between GARFIELD-AF bleeding score over the HAS-BLED.[5][6]

2020 ESC guidelines on atrial fibrillation recommend assessment of bleeding risk in AF using the HAS-BLED bleeding risk schema as a simple, easy calculation,[7] whereby a score of ≥3 indicates "high risk" and some caution and regular review of the patient is needed.[8] The HAS-BLED score has also been validated in an anticoagulated trial cohort of 7329 people with AF - in this study, the HAS-BLED score offered some improvement in predictive capability for bleeding risk over previously published bleeding risk assessment schemas and was simpler to apply.[9] With the likely availability of new oral anticoagulants that avoid the limitations of warfarin (and may even be safer), more widespread use of oral anticoagulation therapy for stroke prevention in AF is likely.

While their use is recommended in clinical practice guidelines,[10] they are only moderately effective in predicting bleeding risk and don't perform well in predicting hemorrhagic stroke.[11] Bleeding risk may be increased in patients on haemodialysis.[12]

Score

A score of ≥3 indicates "high risk", but does not necessarily mean that an anticoagulant cannot be given, as some risk factors may be modified.[13]

References
  1. Pisters, Ron; Lane, D. A.; Nieuwlaat, R; De Vos, C. B.; Crijns, H. J.; Lip, G. Y. (2010). "A Novel User-Friendly Score (HAS-BLED) to Assess 1-Year Risk of Major Bleeding in Patients with Atrial Fibrillation". Chest. 138 (5): 1093–100. doi:10.1378/chest.10-0134. PMID 20299623.
  2. "HAS-BLED Score for Major Bleeding Risk". MDCalc. Archived from the original on 25 February 2021. Retrieved 11 April 2021.
  3. Dan, Gheorhe-Andre; Steffel, Jan (2019). "4.1. Atrial fibrillation". In Kaski, Juan Carlos; Kjeldsen, Keld Per (eds.). The ESC Handbook on Cardiovascular Pharmacotherapy. Oxford: Oxford University Press. pp. 201–203. ISBN 978-0-19-875993-5.
  4. Apostolakis, Stavros; Lane, Deirdre A.; Guo, Yutao; Buller, Harry; Lip, Gregory Y. H. (28 August 2012). "Performance of the HEMORR(2)HAGES, ATRIA, and HAS-BLED bleeding risk-prediction scores in patients with atrial fibrillation undergoing anticoagulation: the AMADEUS (evaluating the use of SR34006 compared to warfarin or acenocoumarol in patients with atrial fibrillation) study". Journal of the American College of Cardiology. 60 (9): 861–867. doi:10.1016/j.jacc.2012.06.019. ISSN 1558-3597. PMID 22858389.
  5. Fox, Keith A. A.; Lucas, Joseph E.; Pieper, Karen S.; Bassand, Jean-Pierre; Camm, A. John; Fitzmaurice, David A.; Goldhaber, Samuel Z.; Goto, Shinya; Haas, Sylvia; Hacke, Werner; Kayani, Gloria (21 December 2017). "Improved risk stratification of patients with atrial fibrillation: an integrated GARFIELD-AF tool for the prediction of mortality, stroke and bleed in patients with and without anticoagulation". BMJ Open. 7 (12): e017157. doi:10.1136/bmjopen-2017-017157. ISSN 2044-6055. PMC 5778339. PMID 29273652.
  6. Proietti, Marco; Rivera-Caravaca, José Miguel; Esteve-Pastor, María Asunción; Romiti, Giulio Francesco; Marin, Francísco; Lip, Gregory Y. H. (18 September 2018). "Predicting Bleeding Events in Anticoagulated Patients With Atrial Fibrillation: A Comparison Between the HAS-BLED and GARFIELD-AF Bleeding Scores". Journal of the American Heart Association. 7 (18): e009766. doi:10.1161/JAHA.118.009766. ISSN 2047-9980. PMC 6222935. PMID 30371183.
  7. Hindricks, Gerhard; Potpara, Tatjana; Dagres, Nikolaos; Arbelo, Elena; Bax, Jeroen J.; Blomström-Lundqvist, Carina; Boriani, Giuseppe; Castella, Manuel; Dan, Gheorghe-Andrei; Dilaveris, Polychronis E.; Fauchier, Laurent (2020-08-29). "2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS)". European Heart Journal. 42 (5): 373–498. doi:10.1093/eurheartj/ehaa612. ISSN 1522-9645. PMID 32860505.
  8. Lip, Gregory Y.H. (2011). "Implications of the CHA2DS2-VASc and HAS-BLED Scores for Thromboprophylaxis in Atrial Fibrillation". The American Journal of Medicine. 124 (2): 111–4. doi:10.1016/j.amjmed.2010.05.007. PMID 20887966.
  9. Lip, Gregory Y.H.; Frison, Lars; Halperin, Jonathan L.; Lane, Deirdre A. (2011). "Comparative Validation of a Novel Risk Score for Predicting Bleeding Risk in Anticoagulated Patients with Atrial Fibrillation". Journal of the American College of Cardiology. 57 (2): 173–80. doi:10.1016/j.jacc.2010.09.024. PMID 21111555.
  10. Camm, A. J.; Lip, G. Y. H.; De Caterina, R.; Savelieva, I.; Atar, D.; Hohnloser, S. H.; Hindricks, G.; Kirchhof, P.; Bax, J. J.; Baumgartner, H.; Ceconi, C.; Dean, V.; Deaton, C.; Fagard, R.; Funck-Brentano, C.; Hasdai, D.; Hoes, A.; Kirchhof, P.; Knuuti, J.; Kolh, P.; McDonagh, T.; Moulin, C.; Popescu, B. A.; Reiner, Z.; Sechtem, U.; Sirnes, P. A.; Tendera, M.; Torbicki, A.; Vahanian, A.; et al. (2012). "2012 focused update of the ESC Guidelines for the management of atrial fibrillation: An update of the 2010 ESC Guidelines for the management of atrial fibrillation". European Heart Journal. 33 (21): 2719–47. doi:10.1093/eurheartj/ehs253. PMID 22922413.
  11. Shoeb, Marwa; Fang, Margaret C. (2013). "Assessing bleeding risk in patients taking anticoagulants". Journal of Thrombosis and Thrombolysis. 35 (3): 312–9. doi:10.1007/s11239-013-0899-7. PMC 3888359. PMID 23479259.
  12. Elliott, Meghan J.; Zimmerman, Deborah; Holden, Rachel M. (2007). "Warfarin Anticoagulation in Hemodialysis Patients: A Systematic Review of Bleeding Rates". American Journal of Kidney Diseases. 50 (3): 433–40. doi:10.1053/j.ajkd.2007.06.017. PMID 17720522.
  13. Kiser, Kathryn (2017). Oral Anticoagulation Therapy: Cases and Clinical Correlation. Springer. p. 20. ISBN 9783319546438.
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