The HAS-BLED Score Has Better Prediction Accuracy for Major Bleeding Than the CHADS2 or CHA2DS2-VASc Scores in Anticoagulated Patients With Atrial Fibrillation

Study Questions:

What is the predictive ability of a specific bleeding risk score, HAS-BLED, at predicting major bleeding, as compared to CHADS2 and CHA2DS2-VASc in anticoagulated patients with atrial fibrillation (AF)?


The investigators recruited 1,370 consecutive AF patients (49% male; median age 76) on oral anticoagulation from their outpatient anticoagulation clinic, all of whom were anticoagulated with acenocoumarol and had an international normalized ratio between 2.0 and 3.0 during the preceding 6 months. During follow-up, major bleeding events were identified by the 2005 International Society on Thrombosis and Hemostasis criteria. Model performance was evaluated by calculating c-statistics, and the improvement in predictive accuracy was evaluated by calculating the net reclassification improvement (NRI) and integrated discrimination improvement (IDI).


After a median follow-up of 996 (802-1,254) days, 114 (3.0%/year) presented with a major bleeding event; of these, 31 were intracranial hemorrhages (0.8%/year). Based on c-statistics, HAS-BLED had a superior model performance to both CHADS2 and CHA2DS2-VASc (both p < 0.001). Both NRI and IDI analyses also showed that HAS-BLED was more accurately associated with major bleeding compared to CHADS2 and CHA2DS2-VASc scores.


The authors concluded that in anticoagulated AF patients, a validated specific bleeding risk score, HAS-BLED, should be used for assessing major bleeding.


This study suggests that that the HAS-BLED score has modest, but significantly better prediction accuracy than stroke stratification scores (CHADS2 and CHA2DS2-VASc) for major bleeding events in anticoagulated AF patients. The practice of using CHADS2 and CHA2DS2-VASc as a measure of high bleeding risk should thus be avoided, due to its inferior predictive performance to the HAS-BLED score. The HAS-BLED score is recommended in major guidelines to identify patients potentially at risk of bleeding, and to make clinicians think about correcting the potentially reversible bleeding risk factors. The guidelines also emphasize that a high HAS-BLED score should not be used as a reason to withhold anticoagulation therapy.

Keywords: International Normalized Ratio, Blood Coagulation, Stroke, Intracranial Hemorrhages, Follow-Up Studies, Ischemic Attack, Transient, Outpatients, Thrombosis, Risk Factors

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