Improvement of HAS-BLED bleeding score predictive capability by changing the definition of renal dysfunction in Japanese atrial fibrillation patients on anticoagulation therapy.
OBJECTIVE
Severe chronic kidney disease (CKD) is a risk factor for hemorrhagic events in atrial fibrillation (AF) patients on anticoagulation therapy. We postulated that even moderate CKD may be a risk factor for hemorrhage and this recognition would improve predictive capabilities of hemorrhagic risk stratification models in Japanese patients.


METHODS
In this prospective study, 231 non-valvular AF patients were divided into three groups according to estimated glomerular filtration rate (eGFR) and followed-up for a median of 7.1 years. The clinical endpoint was a major hemorrhagic event (MHE). HAS-BLED score was calculated for the cohort and the predictive capability of the original HAS-BLED score was compared with that in which renal dysfunction was redefined as eGFR<60mL/min/1.73m(2).


RESULTS
Forty-four MHEs occurred during follow-up. Compared to no/mild CKD group (≥60mL/min/1.73m(2)), both moderate (30-59mL/min/1.73m(2)) and severe (<30mL/min/1.73m(2)) CKD groups had higher MHE risks (log rank: both p<0.001). MHE risk of patients with moderate CKD was more than threefold higher than the no/mild CKD group even after adjusting for other risk factors (hazard ratio 3.8, 95% confidence interval 1.7-8.7). The C-statistic in receiver-operating curve analysis was numerically but not significantly superior in modified HAS-BLED score compared to original HAS-BLED score (0.67 and 0.64, respectively; p=0.55). However, using modified HAS-BLED score was associated with significant improvement of net reclassification improvement (0.50, p=0.002) and integrated discrimination improvement (0.033, p=0.043).


CONCLUSIONS
Moderate CKD contributes to the risk of future major hemorrhagic events in AF patients. Modification of HAS-BLED score by changing the definition of renal failure markedly improved predictive capability.
Department of Cardiology, Kameda Medical Center, Chiba, Japan.
Makoto
M
Suzuki
Department of Cardiology, Kameda Medical Center, Chiba, Japan. Electronic address: yuya8950@gmail.com.
Yuya
Y
Matsue
Department of Cardiology, Kameda Medical Center, Chiba, Japan.
Rena
R
Nakamura
Department of Cardiology, Kameda Medical Center, Chiba, Japan.
Akihiko
A
Matsumura
Department of Cardiology, Kameda Medical Center, Chiba, Japan.
Yuji
Y
Hashimoto
D000368:Aged; D000925:Anticoagulants / Q000009:adverse effects / Q000627:therapeutic use*; D044466:Asian People; D001281:Atrial Fibrillation / Q000150:complications / Q000188:drug therapy*; D005260:Female; D005919:Glomerular Filtration Rate; D006470:Hemorrhage / Q000139:chemically induced / Q000150:complications / Q000175:diagnosis*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011446:Prospective Studies; D051436:Renal Insufficiency, Chronic / Q000150:complications / Q000175:diagnosis*; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index
D000925:Anticoagulants
Anticoagulation; Atrial fibrillation; Chronic kidney disease; Hemorrhagic complication; Warfarin