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HAS-BLED Score for Major Bleeding Risk
HAS-BLED Score for Major Bleeding Risk
Assesses bleeding risk in atrial fibrillation patients on anticoagulation
HAS-BLED Score for Major Bleeding Risk
HAS-BLED Score for Major Bleeding Risk
Assesses bleeding risk in atrial fibrillation patients on anticoagulation
Instructions
The HAS-BLED Score helps estimate the 1-year risk of major bleeding in patients with atrial fibrillation who are receiving anticoagulation therapy. Each clinical factor is assigned a point, and the total score provides a bleeding risk estimate. Clinicians should gather patient history, laboratory values, and comorbid conditions, then sum the score. The tool is used to balance bleeding risk against stroke prevention benefits of anticoagulation.
Overview
When to use
Why use
Evidences
Interpretation
HAS-BLED Score | Risk Level |
0 – 1 | Low Risk |
2 | Moderate Risk |
≥ 3 | High Risk |
Developed from the Euro Heart Survey cohort, HAS-BLED assigns one point each for Hypertension, Abnormal renal/liver function (1 point each), Stroke, Bleeding history/predisposition, Labile INR, Elderly (age >65), and Drugs/alcohol (1 point each); total range 0–9 with higher scores indicating greater bleeding risk over 1 year on antithrombotic therapy. The score was designed to be simple and actionable, highlighting modifiable factors (e.g., uncontrolled BP, interacting drugs, labile INRs) to target before and during anticoagulation.
https://pubmed.ncbi.nlm.nih.gov/20299623/
Adults with atrial fibrillation being considered for or receiving oral anticoagulation, primarily to structure bleeding risk assessment and modifiable risk factor management alongside stroke risk tools like CHA2DS2‑VASc; not a tool to deny indicated anticoagulation. A score ≥3 signals the need for more frequent reviews, BP control, renal/hepatic monitoring, and avoidance of concomitant NSAIDs/antiplatelets unless clearly indicated
https://academic.oup.com/eurheartjsupp/article/22/Supplement_O/O53/6043869?login=false
Early independent validation across anticoagulated AF cohorts showed comparable or superior discrimination versus ATRIA and HEMORR2HAGES in multiple studies, with meta-analyses indicating similar c-statistics among bleeding-specific scores and superiority over stroke scores misused for bleeding prediction.
https://pmc.ncbi.nlm.nih.gov/articles/PMC6490831/
Commentary on the 2024 ESC AF guideline update highlights the removal of a mandated structured bleeding score while reiterating not to stop OAC solely due to bleeding risk and to focus on factor mitigation; U.S. sources continue to reference HAS‑BLED in routine monitoring contexts.
https://pmc.ncbi.nlm.nih.gov/articles/PMC11865665/
Meta-analytic data indicate modest discrimination (c≈0.60–0.65) for HAS‑BLED, with calibration varying by cohort; performance is broadly similar to ATRIA/ORBIT and inferior to biomarker-enriched models like ABC in some analyses, though clinical actionability for modifiable factors remains a strength.
Overview
When to use
Why use
Evidences
The HAS-BLED Score is a validated clinical tool designed to identify patients with atrial fibrillation (AF) who are at increased risk of major bleeding when receiving oral anticoagulation therapy. While anticoagulants reduce the risk of ischemic stroke in AF, they also carry a significant bleeding risk, particularly in individuals with multiple comorbidities or frailty. This scoring system provides a structured method for clinicians to quantify bleeding risk and incorporate it into shared decision-making.
The acronym HAS-BLED stands for:
Hypertension
Abnormal renal and liver function
Stroke history
Bleeding history or predisposition
Labile INR
Elderly (age >65)
Drugs or alcohol use
Each risk factor contributes 1 point, with the total score ranging from 0 to 9. A higher score reflects greater bleeding risk, with scores ≥3 indicating high risk that warrants closer monitoring and careful consideration of anticoagulation strategies.
Importantly, the HAS-BLED score is not meant to exclude patients from anticoagulation but to highlight those who may benefit from targeted interventions, such as optimizing blood pressure, avoiding unnecessary antiplatelet therapy, adjusting alcohol intake, and ensuring INR stability in those on warfarin
Overview
When to use
Why use
Evidences
Interpretation
HAS-BLED Score | Risk Level |
0 – 1 | Low Risk |
2 | Moderate Risk |
≥ 3 | High Risk |
Developed from the Euro Heart Survey cohort, HAS-BLED assigns one point each for Hypertension, Abnormal renal/liver function (1 point each), Stroke, Bleeding history/predisposition, Labile INR, Elderly (age >65), and Drugs/alcohol (1 point each); total range 0–9 with higher scores indicating greater bleeding risk over 1 year on antithrombotic therapy. The score was designed to be simple and actionable, highlighting modifiable factors (e.g., uncontrolled BP, interacting drugs, labile INRs) to target before and during anticoagulation.
https://pubmed.ncbi.nlm.nih.gov/20299623/
Adults with atrial fibrillation being considered for or receiving oral anticoagulation, primarily to structure bleeding risk assessment and modifiable risk factor management alongside stroke risk tools like CHA2DS2‑VASc; not a tool to deny indicated anticoagulation. A score ≥3 signals the need for more frequent reviews, BP control, renal/hepatic monitoring, and avoidance of concomitant NSAIDs/antiplatelets unless clearly indicated
https://academic.oup.com/eurheartjsupp/article/22/Supplement_O/O53/6043869?login=false
Early independent validation across anticoagulated AF cohorts showed comparable or superior discrimination versus ATRIA and HEMORR2HAGES in multiple studies, with meta-analyses indicating similar c-statistics among bleeding-specific scores and superiority over stroke scores misused for bleeding prediction.
https://pmc.ncbi.nlm.nih.gov/articles/PMC6490831/
Commentary on the 2024 ESC AF guideline update highlights the removal of a mandated structured bleeding score while reiterating not to stop OAC solely due to bleeding risk and to focus on factor mitigation; U.S. sources continue to reference HAS‑BLED in routine monitoring contexts.
https://pmc.ncbi.nlm.nih.gov/articles/PMC11865665/
Meta-analytic data indicate modest discrimination (c≈0.60–0.65) for HAS‑BLED, with calibration varying by cohort; performance is broadly similar to ATRIA/ORBIT and inferior to biomarker-enriched models like ABC in some analyses, though clinical actionability for modifiable factors remains a strength.
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