title: Recalibration of the HAS-BLED Score: Should Hemorrhagic Stroke Account for One or Two Points?
abstract: After a hemorrhagic stroke, it is uncertain whether this event scores one point (either for stroke or bleeding) or two points (one point each for stroke and bleeding) on the bleeding risk score termed HAS-BLED (hypertension, abnormal renal/liver function [one or two points], stroke, bleeding history or predisposition, labile international normalized ratio [INR], elderly [> 65 years], drugs/alcohol concomitantly [one or two points]). We investigated the value of a recalibration of the HAS-BLED score to account for two points from a hemorrhagic stroke. Data were analyzed from the Danish nationwide cohort of patients with incident atrial fibrillation (AF) from January 1999 to December 2013. The primary outcome in this observational study was major bleeding. The original and the recalibrated HAS-BLED scores were assessed, and the event rates of major bleeding were calculated. The predictive accuracy of major bleeding was compared by using C-statistics, the net reclassification index (NRI), and integrated discrimination improvement (IDI). An event rate for major bleeding of 4.3 per 100 person-years was recorded in the 210,299 patients with AF. The C-statistics for the two scores were modest: 0.613 (95% CI, 0.607-0.619) for the original score and 0.616 (95% CI, 0.610-0.622) for the recalibrated score. The NRI was 10.0% (95% CI, 7.6-12.4). The relative IDI was 23.6% (95% CI, 15.7-31.5), reflecting that the recalibrated HAS-BLED score more accurately predicted bleeding events. Recalibration of the "S" component in the HAS-BLED score (counting two points for a hemorrhagic stroke) resulted in an increase in the C-statistics, NRI, and IDI. This approach could potentially aid physicians in more accurate assessments of bleeding risk in patients with AF.
authors.affiliation: Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark.
authors.forename: Peter Brønnum
authors.initials: PB
authors.lastname: Nielsen
authors.affiliation: Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark.
authors.forename: Torben Bjerregaard
authors.initials: TB
authors.lastname: Larsen
authors.affiliation: Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark; University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom. Electronic address: g.y.h.lip@bham.ac.uk.
authors.forename: Gregory Y H
authors.initials: GYH
authors.lastname: Lip
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002543:Cerebral Hemorrhage / Q000097:blood / Q000150:complications / Q000175:diagnosis*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D019934:International Normalized Ratio; D008297:Male; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors; D012720:Severity of Illness Index; D020521:Stroke / Q000175:diagnosis* / Q000209:etiology
keywords: atrial fibrillation; cardiology; clinical decision making; stroke