The HAS-BLED score has better prediction accuracy for major bleeding than CHADS2 or CHA2DS2-VASc scores in anticoagulated patients with atrial fibrillation.
OBJECTIVE
The aim of this study was to test the hypothesis that a specific bleeding risk score, HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol concomitantly), was better at predicting major bleeding compared with CHADS2 (congestive heart failure, hypertension, 75 years of age or older, diabetes mellitus, and previous stroke or transient ischemic attack) and CHA2DS2-VASc (congestive heart failure, hypertension, 75 years of age and older, diabetes mellitus, previous stroke or transient ischemic attack, vascular disease, 65 to 74 years of age, female) in anticoagulated atrial fibrillation (AF) patients.


BACKGROUND
The CHADS2 and CHA2DS2-VASc scores are well-validated stroke risk prediction scores for AF, but are also associated with increased bleeding and mortality.


METHODS
We recruited 1,370 consecutive AF patients (49% male; median age, 76 years) receiving oral anticoagulation therapy from our outpatient anticoagulation clinic, all of whom were receiving acenocoumarol and had an international normalized ratio between 2.0 and 3.0 during the preceding 6 months. During follow-up, major bleeding events were identified by the 2005 International Society on Thrombosis and Haemostasis criteria. Model performance was evaluated by calculating the C-statistic, and the improvement in predictive accuracy was evaluated by calculating the net reclassification improvement and integrated discrimination improvement.


RESULTS
After a median follow-up of 996 (range, 802 to 1,254) days, 114 patients (3.0%/year) presented with a major bleeding event; 31 of these events were intracranial hemorrhages (0.8%/year). Based on the C-statistic, HAS-BLED had a model performance superior to that of both CHADS2 and CHA2DS2-VASc (both p < 0.001). Both net reclassification improvement and integrated discrimination improvement analyses also show that HAS-BLED was more accurately associated with major bleeding compared with CHADS2 and CHA2DS2-VASc scores.


CONCLUSIONS
In anticoagulated AF patients, a validated specific bleeding risk score, HAS-BLED, should be used for assessing major bleeding. The practice of using CHADS2 and CHA2DS2-VASc as a measure of high bleeding risk should be discouraged, given its inferior predictive performance compared with the HAS-BLED score.
Hematology and Medical Oncology Unit, Hospital Universitario Morales Meseguer, University of Murcia, Murcia, Spain.
Vanessa
V
Roldán
Francisco
F
Marín
Sergio
S
Manzano-Fernández
Pilar
P
Gallego
Juan Antonio
JA
Vílchez
Mariano
M
Valdés
Vicente
V
Vicente
Gregory Y H
GY
Lip
D000074:Acenocoumarol / Q000008:administration & dosage / Q000009:adverse effects*; D000328:Adult; D000367:Age Factors; D000368:Aged; D000428:Alcohol Drinking / Q000009:adverse effects; D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects*; D001281:Atrial Fibrillation / Q000150:complications*; D048909:Diabetes Complications; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000150:complications; D006470:Hemorrhage / Q000139:chemically induced*; D006801:Humans; D006973:Hypertension / Q000150:complications; D019934:International Normalized Ratio; D002546:Ischemic Attack, Transient / Q000150:complications; D007668:Kidney / Q000378:metabolism; D008099:Liver / Q000378:metabolism; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000150:complications / Q000209:etiology / Q000517:prevention & control*; D019966:Substance-Related Disorders / Q000150:complications
D000925:Anticoagulants; D000074:Acenocoumarol
AF; CHA(2)DS(2)-VASc; CHADS(2); CI; HAS-BLED; HR; IDI; INR; NRI; OAC; VKA; anticoagulation; atrial fibrillation; bleeding; confidence interval; congestive heart failure, hypertension, 75 years of age and older, diabetes mellitus, previous stroke or transient ischemic attack, vascular disease, 65 to 74 years of age, female; congestive heart failure, hypertension, 75 years of age or older, diabetes mellitus, and previous stroke or transient ischemic attack; hazard ratio; hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol concomitantly; integrated discrimination improvement; international normalized ratio; net reclassification improvement; oral anticoagulation; risk prediction; stroke; vitamin K antagonist