Point-of-Care Guides

Assessing Bleeding Risk in Patients Taking Anticoagulants

 

Am Fam Physician. 2017 Oct 1;96(7):465-466.

Author disclosure: No relevant financial affiliations.

Clinical Question

What is the best way to assess bleeding risk in patients with atrial fibrillation who are taking anticoagulants?

Evidence Summary

Family physicians are often faced with the dilemma of balancing the benefit of stroke prevention with the risk of major bleeding when deciding on anticoagulation treatment in patients with atrial fibrillation. Over the past 10 years, several decision support tools have been developed and validated to assess the risk of major bleeding in patients taking anticoagulants. Major bleeding is typically defined as bleeding that requires hospitalization or transfusion, or a decrease in hemoglobin of at least 2 g per dL (20 g per L). Most tools share common risk factors, such as advanced age, previous bleeding, and renal/liver impairment.1,2

The ATRIA tool includes five risk factors and was developed in a study of 9,186 patients with nontransient, nonvalvular atrial fibrillation who were receiving warfarin (Coumadin), with five-year follow-up.3 The major limitation is the lack of information about aspirin use in the study patients. The HAS-BLED tool (https://www.mdcalc.com/has-bled-score-major-bleeding-risk) includes seven risk factors and was developed in a study of 3,978 patients with nontransient, nonvalvular atrial fibrillation who were receiving oral anticoagulant monotherapy, an oral anticoagulant combined with an antiplatelet drug, an antiplatelet drug alone, or no anti-thrombotic therapy.4 The overall mean age was 67 years, and 59% of study patients were men. Patients were followed for one year to assess for major bleeding events. The limitation of this tool is that 25% of the data regarding the occurrence of major bleeding during follow-up were missing, contributing to a very low major bleeding rate of 1.5%.4 This may introduce the possibility of selection bias. The HAS-BLED tool is currently recommended by the European Society of Cardiology 5 and the Canadian Cardiovascular Society 6  for bleeding risk assessment in patients with atrial fibrillation. Both tools are summarized in Table 1.3,4

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Table 1.

Comparison of Decision Support Tools in the Assessment of Bleeding Risk in Patients Taking Anticoagulants

Risk factorsPoints

HAS-BLED (2010)4

Prior bleeding

1

Age > 65 years

1

Hypertension

1

Renal disease* or liver disease†

1 or 2

Stroke

1

Labile international normalized ratios

1

Drug (aspirin) or alcohol use

1 or 2

Total score‡:

ATRIA (2011)3

Prior bleeding

1

Age > 75 years

2

Severe renal disease§

3

Anemia‖

3

Hypertension

1

Total score¶:


*—Dialysis, renal transplantation, or serum creatinine > 2.26 mg per dL (199.8 μmol per L).

†—Cirrhosis; bilirubin > two times the upper normal limit that is associated with alanine transaminase, aspartate transaminase, or alkaline phosphatase > three times the upper normal limit.

‡—0 points = low risk; 1 to 2 points = moderate risk; ≥ 3 points = high risk.

§—Dialysis or glomerular filtration rate < 30 mL per minute.

‖—Hemoglobin < 13 g per dL (130 g per L) in men and < 12 g per dL (120 g per L) in women.

¶—0 to 3 points = low risk; 4 points = moderate risk; 5 to 10 points = high risk.

See https://www.mdcalc.com/has-bled-score-major-bleeding-risk for an online calculator based on the HAS-BLED scoring system.

Information from references 3 and 4.

Table 1.

Comparison of Decision Support Tools in the Assessment of Bleeding Risk in Patients Taking Anticoagulants

Risk factorsPoints

HAS-BLED (2010)4

Prior bleeding

1

Age > 65 years

1

Hypertension

1

Renal disease* or liver disease†

1 or 2

Stroke

1

Labile international normalized ratios

1

Drug (aspirin) or alcohol use

1 or 2

Total score‡:

ATRIA (2011)3

Prior bleeding

1

Age > 75 years

2

Severe renal disease§

3

Anemia‖

3

Hypertension

1

Total score¶:


*—Dialysis, renal transplantation, or serum creatinine > 2.26 mg per dL (199.8 μmol per L).

†—Cirrhosis; bilirubin > two times the upper normal limit that is associated with alanine transaminase, aspartate transaminase, or alkaline phosphatase > three times the upper normal limit.

‡—0 points = low risk; 1 to 2 points = moderate risk; ≥ 3 points = high risk.

§—Dialysis or glomerular filtration rate < 30 mL per minute.

‖—Hemoglobin < 13 g per dL (130 g per L) in men and < 12 g per dL (120 g per L) in women.

¶—0 to 3 points = low risk; 4 points = moderate risk; 5 to 10 points = high risk.

See https://www.mdcalc.com/has-bled-score-major-bleeding-risk for an online calculator based on the HAS-BLED scoring system.

Information from references 3 and 4.

In several retrospective studies, the HAS-BLED tool showed better or equivalent predictive accuracy when compared with the ATRIA tool710  (eTable A). Higher-quality evidence from a prospective cohort study showed better predictive value with the HAS-BLED tool (bleeding risk of 0%, 1.4%, and 9.3% in low-, moderate-, and high-risk groups, respectively) compared with the ATRIA tool (1.9%, 9.1%, and 6.5%).11 However, in the same study, the ATRIA tool identified a larger number of patients as low risk than the HAS-BLED tool (75.6% vs. 2.5%).

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eTable A.

Key Studies Assessing Major Bleeding Risk in Patients with Atrial Fibrillation Who Are Taking Anticoagulants

Risk group

LowModerateHigh

StudyTotal patients (%)Patients with major bleeding (%)Total patients (%)Patients with major bleeding (%)Total patients (%)Patients with major bleeding (%)

HAS-BLED tool

Apostolakis, et al., 2012A1 (retrospective study)

7.8

1.1

68

1.3

24.1

3.1

Apostolakis, et al., 2013A2 (retrospective study)

16

0.8

77.9

3.6

6

5.8

Lip, et al., 2012A3 (retrospective study)

17.5

3.9

64.6

7.4

17.9

12.3

Roldán, et al., 2013A4 (prospective study)

2.5

0

63

1.4

35

9.3

ATRIA tool

Apostolakis, et al., 2012A1 (retrospective study)

90

1.5

4.5

2.9

5.6

3.9

Apostolakis, et al., 2013A2 (retrospective study)

89

2.9

4.2

2.1

6.7

7.2

Roldán, et al., 2013A4 (prospective study)

75.6

1.9

8.5

9.1

16

6.5


A1. Apostolakis S, Lane DA, Guo Y, Buller H, Lip GY. Performance of the HEMORR(2)HAGES, ATRIA, and HAS-BLED bleeding risk-prediction scores in patients with atrial fibrillation undergoing anticoagulation: the AMADEUS (evaluating the use of SR34006 compared to warfarin or acenocoumarol in patients with atrial fibrillation) study. J Am Coll Cardiol . 2012;60(9):861–867.

A2. Apostolakis S, Lane DA, Guo Y, Buller H, Lip GY. Performance of the HEMORR 2 HAGES, ATRIA, and HAS-BLED bleeding risk-prediction scores in nonwarfarin anticoagulated atrial fibrillation patients. J Am Coll Cardiol. 2013;61(3):386–387.

A3. Lip GY, Banerjee A, Lagrenade I, Lane DA, Taillandier S, Fauchier L. Assessing the risk of bleeding in patients with atrial fibrillation: the Loire Valley Atrial Fibrillation project. Circ Arrhythm Electrophysiol. 2012;5(5):941–948.

A4. Roldán V, Marín F, Fernández H, et al. Predictive value of the HAS-BLED and ATRIA bleeding scores for the risk of serious bleeding in a “real-world” population with atrial fibrillation receiving anticoagulant therapy. Chest. 2013;143(1):179–184.

eTable A.

Key Studies Assessing Major Bleeding Risk in Patients with Atrial Fibrillation Who Are Taking Anticoagulants

Risk group

LowModerateHigh

StudyTotal patients (%)Patients with major bleeding (%)Total patients (%)Patients with major bleeding (%)Total patients (%)Patients with major bleeding (%)

HAS-BLED tool

Apostolakis, et al., 2012A1 (retrospective study)

7.8

1.1

68

1.3

24.1

3.1

Apostolakis, et al., 2013A2 (retrospective study)

16

0.8

77.9

3.6

6

5.8

Lip, et al., 2012A3 (retrospective study)

17.5

3.9

64.6

7.4

17.9

12.3

Roldán, et al., 2013A4 (prospective study)

2.5

0

63

1.4

35

9.3

ATRIA tool

Apostolakis, et al., 2012A1 (retrospective study)

90

1.5

4.5

2.9

5.6

3.9

Apostolakis, et al., 2013A2 (retrospective study)

89

2.9

4.2

2.1

6.7

7.2

Roldán, et al., 2013A4 (prospective study)

75.6

1.9

8.5

9.1

16

6.5


A1. Apostolakis S, Lane DA, Guo Y, Buller H, Lip GY. Performance of the HEMORR(2)HAGES, ATRIA, and HAS-BLED bleeding risk-prediction scores in patients with atrial fibrillation undergoing anticoagulation: the AMADEUS (evaluating the use of SR34006 compared to warfarin or acenocoumarol in patients with atrial fibrillation) study. J Am Coll Cardiol . 2012;60(9):861–867.

A2. Apostolakis S, Lane DA, Guo Y, Buller H, Lip GY. Performance of the HEMORR 2 HAGES, ATRIA, and HAS-BLED bleeding risk-prediction scores in nonwarfarin anticoagulated atrial fibrillation patients. J Am Coll Cardiol. 2013;61(3):386–387.

A3. Lip GY, Banerjee A, Lagrenade I, Lane DA, Taillandier S, Fauchier L. Assessing the risk of bleeding in patients with atrial fibrillation: the Loire Valley Atrial Fibrillation project. Circ Arrhythm Electrophysiol. 2012;5(5):941–948.

A4. Roldán V, Marín F, Fernández H, et al. Predictive value of the HAS-BLED and ATRIA bleeding scores for the risk of serious bleeding in a “real-world” population with atrial fibrillation receiving anticoagulant therapy. Chest. 2013;143(1):179–184.

A recent systematic review and meta-analysis compared the two scores in the high-bleeding-risk category. The pooled sensitivity and specificity of HAS-BLED for predicting high bleeding risk were 41% and 78%, respectively, compared with 23% and 91% for ATRIA.12 The study was limited because it included heterogeneous studies, not all patients were anticoagulated, and different anticoagulants were used. Overall, the HAS-BLED tool appears to be more sensitive and easy-to-use, and thus is recommended for assessment of major bleeding risk.

Risk stratification using the tools can guide physicians in informed decision making and providing adequate follow-up and monitoring. However, it is important to keep in mind that all the tools share some limitations. All were derived from patients already taking anticoagulants, so patients who were considered too high risk for anticoagulation were not included. Therefore, these tools may underestimate the true risk of major bleeding, especially in older patients with multiple comorbidities. Regardless of which tool is used, physicians should use their best clinical judgment and focus on identifying and minimizing modifiable risk factors such as hypertension, alcohol use, unnecessary concomitant antiplatelet agents, and fall risk.

Applying the Evidence

A 78-year-old woman with a history of hypertension, stroke, and moderate dementia presented at a routine office visit with atrial fibrillation and a normal ventricular rate. She was not in discomfort. It was not clear how long she had been in atrial fibrillation. She used a walker for ambulation. She did not drink alcohol but took aspirin (81 mg) in addition to other medications. She had no history of major bleeding, renal disease, or liver disease.

Her HAS-BLED score was 4, putting her at high risk of major bleeding. Therefore, the physician decided against anticoagulation.

Address correspondence to Juan Qiu, MD, PhD, at jqiu@hmc.psu.edu. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

1. Wang Y, Bajorek B. Safe use of antithrombotics for stroke prevention in atrial fibrillation: consideration of risk assessment tools to support decision-making. Ther Adv Drug Saf. 2014;5(1):21–37....

2. Thomas IC, Sorrentino MJ. Bleeding risk prediction models in atrial fibrillation. Curr Cardiol Rep. 2014;16(1):432.

3. Fang MC, Go AS, Chang Y, et al. A new risk scheme to predict warfarin-associated hemorrhage: The ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) Study. J Am Coll Cardiol. 2011;58(4):395–401.

4. Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation. The Euro Heart Survey. Chest. 2010; 138(5):1093–1100.

5. Camm AJ, Kirchhof P, Lip GY, et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC) [published correction appears in Eur Heart J. 2011;32(9):1172]. Eur Heart J. 2010;31(19): 2369–2429.

6. Cairns JA, Connolly S, McMurtry S, Stephenson M, Talajic M; CCS Atrial Fibrillation Guidelines Committee. Canadian Cardiovascular Society atrial fibrillation guidelines 2010. Can J Cardiol. 2011;27(1):74–90.

7. Apostolakis S, Lane DA, Guo Y, Buller H, Lip GY. Performance of the HEMORR(2)HAGES, ATRIA, and HAS-BLED bleeding risk-prediction scores in patients with atrial fibrillation undergoing anticoagulation: the AMADEUS (evaluating the use of SR34006 compared to warfarin or acenocoumarol in patients with atrial fibrillation) study. J Am Coll Cardiol. 2012;60(9):861–867.

8. Lip GY, Banerjee A, Lagrenade I, Lane DA, Taillandier S, Fauchier L. Assessing the risk of bleeding in patients with atrial fibrillation: the Loire Valley Atrial Fibrillation project. Circ Arrhythm Electrophysiol. 2012;5(5):941–948.

9. Fauchier L, Chaize G, Gaudin AF, Vainchtock A, Rushton-Smith SK, Cotté FE. Predictive ability of HAS-BLED, HEMORR2HAGES, and ATRIA bleeding risk scores in patients with atrial fibrillation. A French nationwide cross-sectional study. Int J Cardiol. 2016;217:85–91.

10. Apostolakis S, Lane DA, Guo Y, Buller H, Lip GY. Performance of the HEMORR 2 HAGES, ATRIA, and HAS-BLED bleeding risk-prediction scores in nonwarfarin anticoagulated atrial fibrillation patients. J Am Coll Cardiol. 2013;61(3):386–387.

11. Roldán V, Marín F, Fernández H, et al. Predictive value of the HAS-BLED and ATRIA bleeding scores for the risk of serious bleeding in a “real-world” population with atrial fibrillation receiving anticoagulant therapy. Chest. 2013;143(1):179–184.

12. Caldeira D, Costa J, Fernandes RM, Pinto FJ, Ferreira JJ. Performance of the HAS-BLED high bleeding-risk category, compared to ATRIA and HEMORR2HAGES in patients with atrial fibrillation: a systematic review and meta-analysis. J Interv Card Electrophysiol. 2014;40(3):277–284.

This guide is one in a series that offers evidence-based tools to assist family physicians in improving their decision making at the point of care.

This series is coordinated by Mark H. Ebell, MD, MS, Deputy Editor for Evidence-Based Medicine.

A collection of Point-of-Care Guides published in AFP is available at https://www.aafp.org/afp/poc.

 

 

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