HAS-BLED for Assessing Bleeding Risk with Anticoagulation: Best of the Mediocre
Notwithstanding a lackluster performance, HAS-BLED beat two other scoring systems in a comparative analysis of trial data.
Bleeding continues to be the Achilles heel of systemic anticoagulation, whether the agent used is warfarin or any of the new anticoagulants entering the market. Predictive models for bleeding include the following:
HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol)
HEMORR2HAGES (hepatic or renal disease, ethanol abuse, malignancy, elderly, reduced platelet count or function, rebleeding, hypertension, anemia, genetic factors, excessive fall risk, stroke)
ATRIA (anticoagulation and risk factors in atrial fibrillation)
Investigators for the AMADEUS trial comparing warfarin with idraparinux (JW Gen Med Feb 26 2008) retrospectively applied all three scoring systems to the 2293 patients randomized to the warfarin arm. Although none of the three demonstrated more than modest efficacy in predicting any clinically relevant bleeding (c-index range, 0.50–0.60), HAS-BLED — the simplest to use — outperformed the others, especially with regard to intracranial hemorrhage (c-index, 0.75).
Apostolakis S et al. Performance of the HEMORR2HAGES, 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. J Am Coll Cardiol 2012 Aug 28; 60:861.