HAS-BLED score more accurate than stroke scores at predicting major bleeding in anticoagulated AF patients


A new study has identified that, in anticoagulated patients with atrial fibrillation (AF), the HAS-BLED score has better prediction accuracy for major bleeding than the CHADS2 or CHA2DS2-VASc scores. The study was published online on 18 September in the Journal of the American College of Cardiology.

Vanessa Roldan (Hematology and Medical Oncology Unit, Hospital Universitario Morales Meseguer, University of Murcia, Spain) and others wrote: “The CHADS2 and CHA2DS2-VASc scores are well validated stroke risk prediction scores for atrial fibrillation, but are also associated with increased bleeding and mortality.” Therefore, they set out to test if the specific bleeding score-HAS-BLED (Hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalised ratio, elderly (> 65 years), drugs/alcohol concomitantly)-was better at predicting major bleeding, compared to the stroke stratification CHADS2 or CHA2DS2-VASc scores, in patients with atrial fibrillation undergoing anticoagulation.

In the study, Roldan et al included 1,370 consecutive atrial fibrillation patients (49% male, median age 76) who were entered during 2007 and the first trimester of 2008 in the authors’ outpatient anticoagulation clinic database. According to the researchers, all patients were anticoagulated with acenocoumarol and consistently achieved an international normalised ratio (INR) between 2.0 and 3.0 during the previous six months of clinic visits. Major bleeding events were defined by the 2005 International Society on Thrombosis and Haemostasis criteria. C-statistics were used to evaluate performance and the net reclassification improvement and integrated discrimination improvement were used to evaluate improvement in predictive accuracy.


After a median follow-up of 996 days, 114 (3.0%/year) patients experienced a major bleeding event, of these, 31 were intracranial haemorrhages (0.8%/year). One hundred and sixty patients (4.3%/year) died during the follow-up (18 as a result of a haemorrhagic event). Roldan et al reported that the HAS-BLED score showed a superior model performance for predicting major bleeds than the CHADS2 and CHA2DS2-VASc scores. They said: “Based on reclassification analyses, the probability of correctly predicting serious bleeding events using the HAS-BLED score was particularly reflected in the percentage of events correctly reclassified.”

Roldan told Cardiac Rhythm News: “With this study we have demonstrated that the CHA2DS2-VASc score can suggest the bleeding risk, but HAS-BLED is much better for that purpose.”

Since its first description in 2010, this score [HAS-BLED] has been validated in several population and has been shown to outperform several older or newer more complicated bleeding risk scores [HEMORR2HAGES and ATRIA risk scores],” the authors noted.

Roldan et al concluded: “The use of CHADS2 and CHA2DS2-VASc scores as a measure of high bleeding risk in atrial fibrillation should be discouraged, given its inferior predictive performance to the HAS-BLED score. Thus, a well-validated specific bleeding risk score, HAS-BLED, should be used for assessing major bleeding in anticoagulated atrial fibrillation patients.”