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?


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.


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.


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


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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