Physicians' Academy for Cardiovascular Education

HAS-BLED score better predicts major bleeding in anticoagulated AF patients

Literature - Roldán V, Marín F, Manzano-Fernández S et al. - J Am Coll Cardiol. 2013 Sep 13


The HAS-BLED score has better prediction accuracy for major bleeding than the CHADS2 or CHA2DS2-VASc scores In anticoagulated patients with atrial fibrillation.


Roldán V, Marín F, Manzano-Fernández S et al.
J Am Coll Cardiol. 2013 Sep 13. doi: 10.1016/j.jacc.2013.08.1623. [Epub ahead of print]
 

Background

Different stroke risk stratification schemes exist for atrial fibrillation (AF) patients [1], such as the CHADS2 (Congestive heart failure, Hypertension, Age >75, Diabetes mellitus, and prior Stroke or TIA [Doubled])  score [2]. The more recent CHA2DS2-VASc Cardiac failure or dysfunction, Hypertension, Age ≥75 [Doubled], Diabetes, Stroke [Doubled] – Vascular disease, Age 65-74 and Sex category [Female]) score focuses more on the initial identification of ‘truly low risk’ identification as the initial decision-making step [1,3,4].
Since stroke risk and bleeding risk are closely related, the CHADS2 score closely correlates with bleeding rate [5,6]. As a result, clinicians sometimes use the CHADS2 score or the CHA2DS2-VASc score as an indicator of bleeding risk. This could lead to low use of oral anticoagulation (OAC) in patients with high scores in these risk assessments [7-9].
Specific bleeding risk scores have been developed for patients with AF [10]. The HAS-BLED score (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly) is now recommended in European and Canadian AF guidelines to estimate major bleeding risk in AF patients on anticoagulation [4, 10-12]. HAS-BLED has been shown to be a better predictor of serious bleeding both in clinical trial cohorts [13] and ‘real world’ clinical practice [14,15]. In addition, it is the only risk score that can predict intracranial bleeding in AF [13] and non-AF patients [16].
This study tested the hypothesis that the specific bleeding risk score HAS-BLED has better predictive value for major bleeding than CHADS2 and CHA2DS2-VASc in AF patients on anticoagulation (with acenocoumarol and with a consistent INR between 2.0 and 3.0 over the past 6 months). 1370 patients were included and followed for a median time of 996 (IQR: 802-1254) days. 114 patients presented with a major bleeding event, of which 31 intracranial.

 
Main results

  • Univariate analysis showed predictive value of both the CHADS2 and CHA2DS2-VASc scores for bleeding events, with HR: 1.31 (95% CI:1.14-1.52; p<0.001) and HR: 1.22 (95% CI: 1.09-1.37; p=0.001),respectively. The HAS-BLED score was more predictive for major bleeds, with HR: 1.94 (95% CI: 1.66-2.28; p<0.001).
  • The C-statistics for HAS-BLED (mean 0.69 + SD 0.03, P<0.001) and the multivariable model (0.71 + ).03, P<0.001) were significantly higher than those for CHADS2 (0.59 + 0.03, P=0.002) or CHA2DS2-VASc (0.58 + 0.03, P=0.006) (P<0.001 for both comparisons).
  • After adjustment for HAS-BLED score, both CHADS2 and CHA2DS2-VASc lost their significance in predictive value in the multivariate analysis.
  • Both net reclassification improvement (NRI) and integrated discrimination improvement (IDI) showed that the HAS-BLED score was more accurately associated with major bleeding episodes than with both of the other scores.
 

Conclusion

This study confirms the hypothesis that the HAS-BLED score is of modest but significantly better predictive value than stroke stratification scores CHADS2 and CHA2DS2-VASc, for major bleeding events in anticoagulated AF patients. Consequently, the well-validated and user-friendly HAS-BLED score should be used, while use of the other scores should be avoided to assess high bleeding risk.
 

References

1. Lip GY. Stroke and bleeding risk assessment in atrial fibrillation: when, how, and why? Eur Heart J. 2012 doi:10.1093/eurheartj/ehs435
2. Gage BF, Waterman AD, Shannon W, et al. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA 2001;285:2864-2870.
3. Lip GY, Nieuwlaat R, Pisters R et al. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest 2010; 137:263-72.
4. Camm AJ, Lip GY, De Caterina R, et al; ESC Committee for Practice Guidelines. 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. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J 2012; 33:2719-2747.
5. Poli D, Antonucci E, Marcucci R, et al. Risk of bleeding in very old atrial fibrillation patients on warfarin:
relationship with ageing and CHADS2 score. Thromb Res 2007;121:347-52.
6. Hylek EM, Evans-Molina C, Shea C, et al. Major hemorrhage and tolerability of warfarin in the first year of therapy among elderly patients with atrial fibrillation. Circulation 2007;115:2689-96.
7. Kirchhof P, Nabauer M, Gerth A, et al; AFNET registry investigators. Impact of the type of centre on management of AF patients: surprising evidence for differences in antithrombotic therapy decisions. Thromb Haemost. 2011;105:1010-23.
8. Wilke T, Groth A, Mueller S, et al. Oral anticoagulation use by patients with atrial fibrillation in Germany. Adherence to guidelines, causes of anticoagulation under-use and its clinical outcomes, based on claims-data of 183,448 patients. Thromb Haemost 2012;107:1053-65.
9. Holt TA, Hunter TD, Gunnarsson C, et al. Risk of stroke and oral anticoagulant use in atrial fibrillation: a cross-sectional survey. Br J Gen Pract 2012;62:e710-7.
10. Lip GY, Andreotti F, Fauchier L, et al; European Heart Rhythm Association. Bleeding risk assessment and management in atrial fibrillation patients. Executive Summary of a Position Document from the European Heart Rhythm Association [EHRA], endorsed by the European Society of Cardiology [ESC] Working Group on Thrombosis. Thromb Haemost 2011; 106: 997-1011.
11. Pisters R, Lane DA, Nieuwlaat R, et al. A Novel User-Friendly Score (HAS-BLED) To Assess 1-Year Risk of Major Bleeding in Patients With Atrial Fibrillation: The Euro Heart Survey. Chest 2010; 138:1093-100.
12. Skanes AC, Healey JS, Cairns JA, et al; Canadian Cardiovascular Society Atrial Fibrillation Guidelines
Committee. Focused 2012 update of the Canadian Cardiovascular Society atrial fibrillation guidelines: recommendations for stroke prevention and rate/rhythm control. Can J Cardiol. 2012;28:125-36.
13. Apostolakis S, Lane DA, Guo Y, et al. Performance of the HEMORR(2)HAGES, ATRIA, and HAS-BLED bleeding risk-prediction scores in nonwarfarin anticoagulated atrial fibrillation patients. J Am Coll Cardiol 2013;61:386-7.
14. Roldan V, Marín F, Fernández H, et al. Predictive value of the HAS-BLED and ATRIA bleeding scores for the
risk of serious bleeding in a “real-world” population with atrial fibrillation receiving anticoagulant therapy. Chest 2013;143:179-84.
15. Lip GY, Banerjee A, Lagrenade I, et al. Assessing the risk of bleeding in patients with atrial fibrillation: the Loire Valley Atrial Fibrillation project. Circ Arrhythm Electrophysiol 2012;5:941-8.
16. Lip GY, Lin HJ, Hsu HC et al. Comparative assessment of the HAS-BLED score with other published bleeding risk scoring schemes for intracranial haemorrhage risk in a non-atrial fibrillation population: The Chin-Shan Community Cohort Study. Int J Cardiol 2013 http://dx.doi.org/10.1016/j.ijcard.2012.12.076
 

Find this article on Pubmed

Share this page with your colleagues and friends: