title: A standardized bleeding risk score aligns anticoagulation choices with current evidence.
abstract: OBJECTIVE
  Atrial fibrillation (AF), the most common arrhythmia in elderly patients, accounts for 15% of strokes. Oral anticoagulation (OAC) can reduce the risk of stroke by 60% but is underprescribed. The HAS-BLED score (Hypertension, Abnormal renal or liver function, Stroke, Bleeding, Labile INR, Elderly, Drugs) can predict OAC bleeding complications. The authors hypothesized that use of HAS-BLED can help align decision making with current evidence.
  
  
  METHODS
  The authors developed a survey with four clinical vignettes designed to highlight the complexity in deciding whether to anticoagulate elderly patients with AF. Physicians were randomly assigned to receive the survey either including the HAS-BLED score and the estimated annual risk of bleeding (intervention) or without (control). Following each vignette, participants were asked: (1) whether they would recommend OAC and (2) to estimate the risk of bleeding and stroke. The "appropriate" anticoagulation decision was defined as the choice that minimized the risk of stroke and major bleeding.
  
  
  RESULTS
  A total of 203 physicians were recruited for the survey, with 55 responses obtained (27%). Physicians who were given the HAS-BLED score were 18% more likely to choose appropriate anticoagulation (74% vs. 56%, P < .05). The HAS-BLED score assisted physicians in both choosing to anticoagulate when appropriate and not to anticoagulate when the risk of bleeding outweighed the benefit. Overall, physicians were poor at estimating the risk of stroke (42% correct) and major bleeding (31% correct).
  
  
  CONCLUSIONS
  Presentation of the HAS-BLED score led to an 18% improvement in appropriate OAC choices. Future study should evaluate incorporation of HAS-BLED use in real-time clinical situations.
authors: From the *Department of Medicine, Mount Sinai and University Health Network Hospitals, Toronto, ON, Canada; †Department of Medicine, Mount Sinai Hospital, New York,NY; ‡Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; and §Geriatric Research Education and Clinical Centers, James J Peters VA Medical Center, Bronx, New York, NY.
authors: Arielle S
authors: AS
authors: Berger
authors: Andrew S
authors: AS
authors: Dunn
authors: Amy S
authors: AS
authors: Kelley
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects; D001281:Atrial Fibrillation / Q000150:complications / Q000188:drug therapy; D002170:Canada; D002983:Clinical Competence; D005260:Female; D019538:Health Care Surveys; D006470:Hemorrhage / Q000139:chemically induced / Q000517:prevention & control; D006801:Humans; D008297:Male; D018579:Patient Selection; D010820:Physicians / Q000592:standards / Q000706:statistics & numerical data; D057216:Propensity Score; D058996:Quality Improvement; D011897:Random Allocation; D012015:Reference Standards; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000209:etiology / Q000517:prevention & control; D014481:United States
chemical_list: D000925:Anticoagulants