Accuracy of HAS‐BLED and other bleeding risk assessment tools in predicting major bleeding events in atrial fibrillation: A network meta‐analysis

Abstract

Background Preventing thrombosis is an important part of atrial fibrillation (AF) treatment. However, it may increase the risk of bleeding, and bleeding risk assessment tools' predictive value remains unclear. This network meta‐analysis investigated the sensitivity and specificity of HAS‐BLED, and other bleeding risk assessment tools, to predict major bleeding events in AF patients. Methods The PubMed, EMBASE, and Cochrane Central Register of Controlled Trials databases were searched using keywords, including “AF,” “bleeding,” and “HAS‐BLED,” for results published through 30 November 2018. The predictive sensitivity and specificity of each bleeding risk assessment tool was analyzed by network meta‐analysis. Results Our analysis included 18 studies, recruiting a total of 321 888 people. The bleeding risk assessment tools analyzed in this study included the ABC‐bleeding score, ATRIA, European score, GARFIELD‐AF, HAS‐BLED, HEMORR2HAGES, ORBIT, Shireman, and mOBRI. A comprehensive analysis of sensitivity and specificity, based on an inconsistency model, showed that European score, ABC, and mOBRI have relatively high‐sensitivity but low‐specificity tools, whereas HAS‐BLED and HEMORR2HAGES have balanced sensitivity and specificity. ORBIT, ATRIA, Shireman, and GARFIELD‐AF had relatively high specificity but low sensitivity. A consistency model analysis showed similar results. Conclusions HAS‐BLED is a balanced bleeding risk assessment tool in terms of sensitivity and specificity, whereas the European score, ABC, and mOBRI are high‐sensitivity tools and ORBIT, ATRIA, Shireman, and GARFIELD‐AF are high‐specificity tools.

Impact of atrial fibrillation in critically ill patients admitted to a stepdown unit

“…Both CHA 2 DS 2 -VASc and HAS-BLED scores were originally developed from general AF patients' cohorts and tested on 1-year outcomes. 27,28 Notwithstanding, since then both the scores were largely validated in various cohorts and tested on variable follow-up times [29][30][31] ; indeed, the use of both the scores is currently recommended from most of the international clinical AF guidelines. 32…”

Considerations when choosing an appropriate bleeding risk assessment tool for patients with atrial fibrillation

“…In the current issue of the Journal of Thrombosis and Haemostasis , Chang et al report the results from a network meta‐analysis of 18 studies (n = 321 888 patients) comparing the sensitivity and specificity of the HAS‐BLED model and other risk assessment models for predicting major bleeding events in patients with AF. Overall, Chang et al show that the European score based only on modifiable bleeding risk factors, ABC and mOBRI models had high sensitivity but low specificity, whereas the ORBIT, ATRIA, Shireman, and GARFIELD‐AF registry models had high specificity, but low sensitivity. The network meta‐analysis clearly demonstrates that the HAS‐BLED model was the most balanced in terms of sensitivity and specificity, slightly surpassing the HEMORR 2 HAGES model.…”

“…The study by Chang et al highlights some of the strengths and weaknesses of individual bleeding risk scores, particularly that those with a high sensitivity often had low specificity and vice versa. Although the HAS‐BLED and HEMORR 2 HAGES models were balanced, both demonstrated only modest values of sensitivity and specificity.…”

“…When using the various bleeding risk models as screening tools, it is important to consider the characteristics of the cohort of interest, including the tendency for patients to have a high risk of bleeding (Bayes’ theorem) . As such, Chang et al appropriately suggest that among patients at high risk of bleeding, a model with high sensitivity is desirable, whereas among patients at low risk of bleeding, a model with high specificity is desirable.…”

Bleeding in anticoagulated patients with atrial fibrillation: practical considerations

“…17,18 In the RE -LY (Randomized Evaluation of Long -Term Anticoagulation Therapy) trial, dabigatran 150 mg bid (but not dabigatran 110 mg bid) was associated with an increased risk of major GI bleeding compared thromboembolism, history of bleeding or bleeding diathesis [eg, severe anemia], age >65 years, use of aspirin or nonsteroidal anti -inflammatory drugs, and alcohol abuse) score had the best evidence for predicting bleeding risk (moderate strength of evidence), consistent with other systematic reviews and meta -analyses comparing bleeding risk prediction scores. 35,36 by the C statistic values in the range from 0.5 to 0.65), and numerous studies comparing 2 or more bleeding risk scores yielded conflicting results. [24][25][26][27][28][29][30][31][32][33] In a systemic review commissioned by the Patient -Centered Outcomes Research Institute 34 of 38 studies on bleeding risk prediction, the HAS -BLED (hypertension, abnormal renal and / or liver function, history of stroke or lower clot permeability had an increased risk of ischemic stroke or transient ischemic attack (TIA) (hazard ratio [HR], 6.55; 95% CI, 2.17-19.82) and major bleeds (HR, 10.65; 95%CI, 3.52-32.22), while patients with high permeability had elevated risk of minor bleeding compared with those with low fibrin clot permeability (11.63% per year vs 3.55% per year).…”