Chest
Volume 138, Issue 5, November 2010, Pages 1093-1100
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Original Research
Antithrombotic Therapy
A Novel User-Friendly Score (HAS-BLED) To Assess 1-Year Risk of Major Bleeding in Patients With Atrial Fibrillation: The Euro Heart Survey

https://doi.org/10.1378/chest.10-0134Get rights and content

Objective

Despite extensive use of oral anticoagulation (OAC) in patients with atrial fibrillation (AF) and the increased bleeding risk associated with such OAC use, no handy quantification tool for assessing this risk exists. We aimed to develop a practical risk score to estimate the 1-year risk for major bleeding (intracranial, hospitalization, hemoglobin decrease >2 g/L, and/or transfusion) in a cohort of real-world patients with AF.

Methods

Based on 3,978 patients in the Euro Heart Survey on AF with complete follow-up, all univariate bleeding risk factors in this cohort were used in a multivariate analysis along with historical bleeding risk factors. A new bleeding risk score termed HAS-BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly (>65 years), Drugs/alcohol concomitantly) was calculated, incorporating risk factors from the derivation cohort.

Results

Fifty-three (1.5%) major bleeds occurred during 1-year follow-up. The annual bleeding rate increased with increasing risk factors. The predictive accuracy in the overall population using significant risk factors in the derivation cohort (C statistic 0.72) was consistent when applied in several subgroups. Application of the new bleeding risk score (HAS-BLED) gave similar C statistics except where patients were receiving antiplatelet agents alone or no antithrombotic therapy, with C statistics of 0.91 and 0.85, respectively.

Conclusion

This simple, novel bleeding risk score (HAS-BLED) provides a practical tool to assess the individual bleeding risk of real-world patients with AF, potentially supporting clinical decision making regarding antithrombotic therapy in patients with AF.

Section snippets

Materials and Methods

We used the large population database of the prospective Euro Heart Survey on AF, with data collected between 2003 and 2004. A detailed study outline of the Euro Heart Survey on AF at baseline5 and follow-up assessment18 has been previously described. In summary, 5,333 ambulatory and hospitalized patients with AF from 182 university, nonuniversity, and specialized hospitals among 35 member countries of the European Society of Cardiology were enrolled. Patients had to be ≥18 years of age and

Results

Of the 5,272 patients with AF in the Euro Heart Survey of AF who were discharged alive,5 3,456 (66%) patients without mitral valve stenosis or valvular surgery had 1-year follow-up status regarding major bleeding. The overall mean (SD) age was 66.8 (12.8) years, and the majority were men (59%). Fifty-three (1.5%) patients experienced a major bleed during the first year, including nine (17%) cases of intracerebral hemorrhage. The baseline demographic and clinical characteristics of the 3,456

Discussion

Using a derivation cohort based on the large, real-world population of the Euro Heart Survey on AF, we identified four independent risk factors of major bleeding within 1 year (prior major bleeding, age >65 years, clopidogrel use, and kidney failure). Incorporating these risk factors with other established risk factors from systematic reviews and multivariate analyses,11, 13, 19 we developed and tested a novel, user-friendly bleeding risk score, HAS-BLED, which demonstrated a good predictive

Conclusion

We propose a novel bleeding risk score, HAS-BLED, that provides an easy, practical tool to assess the individual bleeding risk of patients with AF. The use of this simple score may potentially support clinical decision making regarding antithrombotic therapy for stroke prevention.

Acknowledgments

Author contributions: Dr Pisters: contributed to statistical analyses, data interpretation, and drafting of the manuscript.

Dr Lane: contributed to drafting and revision of the manuscript.

Dr Nieuwlaat: contributed to statistical analyses, data interpretation, and drafting of the manuscript.

Dr de Vos: contributed to drafting and revision of the manuscript.

Dr Crijns: contributed to drafting and revision of the manuscript.

Dr Lip: contributed to study design and hypothesis, concept of the HAS-BLED

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    Funding/Support: The Euro Heart Survey has as industry sponsors the main sponsor, AstraZeneca; major sponsor, Sanofi-Aventis; and sponsor, Eucomed. Funding institutions are the Austrian Heart Foundation, Austrian Society of Cardiology, French Federation of Cardiology, Hellenic Cardiological Society, Netherlands Heart Foundation, Portuguese Society of Cardiology, Spanish Cardiac Society, Swedish Heart and Lung Foundation, and individual centers.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

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