Comparison of Bleeding Risk Scores in Patients With Nonvalvular Atrial Fibrillation Starting Direct Oral Anticoagulants

Martínez, César Caro; Andreu-Cayuelas, José M.; Blanco, Pedro J.; Valdés, Mariano; Lorenzo, José Luis Bailén; Manzano‐Fernández, Sergio

doi:10.1016/j.rec.2017.01.021

Cited by 9 publications

(7 citation statements)

References 7 publications

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“…Reasons for article exclusion included: number of bleeding events not reported (15); non‐major bleeding result report (11); conference abstract with insufficient results (9); comparisons based on undesired risk tools (8); reviews (7); duplication reports (4); letter/comment with insufficient results (3); survey on the application of risk tools (1); study only included patients with HAS‐BLED ≤2 (1); studies on non‐AF patients (1). Ultimately, 18 articles, assessing a total of 321 888 people, were included in our analysis (Figure ).…”

Section: Resultsmentioning

confidence: 99%

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

Chang

Xie

et al. 2020

Journal of Thrombosis and Haemostasis

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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.

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Section: Resultsmentioning

confidence: 99%

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

Chang

Xie

et al. 2020

Journal of Thrombosis and Haemostasis

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“…The component of "labile INR" in the HAS-BLED score was available in 10 included studies. "Labile INR" was not applicable in three studies (13)(14)(15) because they only included DOAC-treated patients for analysis. As shown in Supplementary Table 4, all the included studies had high (n = 20, 51%) or unclear (n = 19, 49%) risk of bias according to the PROBAST tool.…”

Section: Study Selectionmentioning

confidence: 99%

Diagnostic Accuracy of the HAS-BLED Bleeding Score in VKA- or DOAC-Treated Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis

Gao

Cai

Yang

et al. 2021

Front. Cardiovasc. Med.

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Background: Several bleeding risk assessment models have been developed in atrial fibrillation (AF) patients with oral anticoagulants, but the most appropriate tool for predicting bleeding remains uncertain. Therefore, we aimed to assess the diagnostic accuracy of the Hypertension, Abnormal liver/renal function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly, Drugs/alcohol concomitantly (HAS-BLED) score compared with other risk scores in anticoagulated patients with AF.Methods: We comprehensively searched the PubMed and Embase databases until July 2021 to identify relevant pieces of literature. The predictive abilities of risk scores were fully assessed by the C-statistic, net reclassification improvement (NRI) and integrated discrimination improvement (IDI) values, calibration data, and decision curve analyses.Results: A total of 39 studies met the inclusion criteria. The C-statistic of the HAS-BLED score for predicting major bleeding was 0.63 (0.61–0.65) in anticoagulated patients regardless of vitamin k antagonists [0.63 (0.61–0.65)] and direct oral anticoagulants [0.63 (0.59–0.67)]. The HAS-BLED had the similar C-statistic to the Hepatic or renal disease, Ethanol abuse, Malignancy, Older, Reduced platelet count or function, Re-bleeding risk, Hypertension (uncontrolled), Anemia, Genetic factors, Excessive fall risk, Stroke (HEMORR2HAGES), the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA), the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT), the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF), or the Age, Biomarkers, Clinical History (ABC) scores, but significantly higher C-statistic than the Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, Stroke/transient ischemic attack history (CHADS2) or the Congestive heart failure/left ventricular ejection fraction ≤ 40%, Hypertension, Age ≥75 years, Diabetes mellitus, Stroke/transient ischemic attack/thromboembolism history, Vascular disease, Age 65–74 years, Sex (female) (CHA2DS2-VASc) scores. NRI and IDI values suggested that the HAS-BLED score performed better than the CHADS2 or the CHA2DS2-VASc scores and had similar or superior predictive ability compared with the HEMORR2HAGES, the ATRIA, the ORBIT, or the GARFIELD-AF scores. Calibration and decision curve analyses of the HAS-BLED score compared with other scores required further assessment due to the limited evidence.Conclusion: The HAS-BLED score has moderate predictive abilities for bleeding risks in patients with AF regardless of type of oral anticoagulants. Current evidence support that the HAS-BLED score is at least non-inferior to the HEMORR2HAGES, the ATRIA, the ORBIT, the GARFIELD-AF, the CHADS2, the CHA2DS2-VASc, or the ABC scores.

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“…Furthermore, while the HAS-BLED outperformed other scores in predicting ICH, we were unable to evaluate this outcome due to a paucity of events-per-predictors [60,65]. Finally, despite encompassing approximately half of MB cases, NGIB, which predominantly included genitourinary bleeding and gross hematuria, has been poorly studied [66][67][68]. Our model predicted NGIB as well as it did MB (c-statistic: 0.67 95% CI 0.64-0.70).…”

Section: Plos Onementioning

confidence: 72%

Predicting major bleeding among hospitalized patients using oral anticoagulants for atrial fibrillation after discharge

et al. 2021

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Aim Real-world predictors of major bleeding (MB) have been well-studied among warfarin users, but not among all direct oral anticoagulant (DOAC) users diagnosed with atrial fibrillation (AF). Thus, our goal was to build a predictive model of MB for new users of all oral anticoagulants (OAC) with AF. Methods We identified patients hospitalized for any cause and discharged alive in the community from 2011 to 2017 with a primary or secondary diagnosis of AF in Quebec’s RAMQ and Med-Echo administrative databases. Cohort entry occurred at the first OAC claim. Patients were categorized according to OAC type. Outcomes were incident MB, gastrointestinal bleeding (GIB), non-GI extracranial bleeding (NGIB) and intracranial bleeding within 1 year of follow-up. Covariates included age, sex, co-morbidities (within 3 years before cohort entry) and medication use (within 2 weeks before cohort entry). We used logistic-LASSO and adaptive logistic-LASSO regressions to identify MB predictors among OAC users. Discrimination and calibration were assessed for each model and a global model was selected. Subgroup analyses were performed for MB subtypes and OAC types. Results Our cohort consisted of 14,741 warfarin, 3,722 dabigatran, 6,722 rivaroxaban and 11,196 apixaban users aged 70–86 years old. The important MB predictors were age, prior MB and liver disease with ORs ranging from 1.37–1.64. The final model had a c-statistic of 0.63 (95% CI 0.60–0.65) with adequate calibration. The GIB and NGIB models had similar c-statistics of 0.65 (95% CI 0.63–0.66) and 0.67 (95% CI 0.64–0.70), respectively. Conclusions MB and MB subtype predictors were similar among DOAC and warfarin users. The predictors selected by our models and their discriminative potential are concordant with published data. Thus, these models can be useful tools for future pharmacoepidemiologic studies involving older oral anticoagulant users with AF.

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Comparison of Bleeding Risk Scores in Patients With Nonvalvular Atrial Fibrillation Starting Direct Oral Anticoagulants

Cited by 9 publications

References 7 publications

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

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

Diagnostic Accuracy of the HAS-BLED Bleeding Score in VKA- or DOAC-Treated Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis

Predicting major bleeding among hospitalized patients using oral anticoagulants for atrial fibrillation after discharge

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