Relation of the Has-Bled Bleeding Risk Score to Major Bleeding, Cardiovascular Events and Mortality in Anticoagulated Patients With Atrial Fibrillation

Study Questions:

How accurately does the HAS-BLED bleeding score predict major bleeds and cardiovascular events?

Methods:

The subjects of this study were 965 patients (median age 76 years) with atrial fibrillation (AF) who were anticoagulated with a vitamin K antagonist for ≥6 months and had an international normalized ratio (INR) of 2-3. The HAS-BLED score consisted of 1 point for hypertension, abnormal renal/liver function, stroke, bleeding history, labile INR, age ≥65 years, and use of drugs/alcohol. Cardiovascular endpoints were defined as stroke/transient ischemic attack, embolism, acute coronary syndrome, acute heart failure, and cardiac death.

Results:

During a median follow-up of 22 months, the annual incidences of cardiovascular events, strokes, hemorrhagic events, intracranial hemorrhage, and mortality were 4.9%, 1.8%, 3.6%, 0.7%, and 4.5%. There was a monotonic relationship between bleeding rate and HAS-BLED score. The bleeding rate significantly exceeded the thromboembolism rate when the HAS-BLED score was >4. The HAS-BLED score had a c-statistic (area under the receiver operator curve) of 0.7 for bleeding, 0.58 for adverse cardiovascular events, and 0.62 for all-cause mortality.

Conclusions:

The authors concluded that the HAS-BLED score is predictive of hemorrhagic complications, adverse cardiovascular events, and mortality in anticoagulated patients with AF.

Perspective:

Some of the variables that are predictive of bleeding (e.g., older age, renal impairment, prior stroke) also are predictive of thromboembolic events. This explains why the HAS-BLED score is predictive not only of bleeding events, but also adverse outcomes related to thromboembolism. The results suggest that if the HAS-BLED score is >4, it may be prudent to avoid oral anticoagulant therapy since the risk of bleeding exceeds that of thromboembolism.

Clinical Topics: Acute Coronary Syndromes, Heart Failure and Cardiomyopathies, Prevention, Acute Heart Failure, Hypertension

Keywords: Vitamin K, Stroke, Acute Coronary Syndrome, Ischemic Attack, Transient, International Normalized Ratio, Thromboembolism, Intracranial Hemorrhages, Heart Failure, Disclosure, Liver, Embolism, Hypertension


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