Incident Risk Factors and Major Bleeding in Patients with Atrial Fibrillation Treated with Oral Anticoagulants: A Comparison of Baseline, Follow-up and Delta HAS-BLED Scores with an Approach Focused on Modifiable Bleeding Risk Factors

Chao, Tze‐Fan; Lin, Yenn‐Jiang; Chang, Shih‐Lin; Liu, Shin-Huei; Hu, Yu‐Feng; Tuan, Ta‐Chuan; Liao, Jo‐Nan; Chung, Fa Po; Chen, Tzeng Ji; Lip, Gregory Y.H.; Chen, Shih‐Ann

doi:10.1055/s-0038-1636534

Cited by 143 publications

(123 citation statements)

References 18 publications

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“…42 Moreover, the follow-up HAS-BLED has more predictive value for major bleeding as compared with baseline HAS-BLED because bleeding risk in AF patients is a dynamic process. 43 Studies have already illustrated that bleeding risk assessment based on modifiable risk factors alone (as proposed by the ESC guidelines) is an inferior strategy compared to a formal bleeding risk score like the HAS-BLED score. 44,45 The ABC-bleeding tool is a recently proposed assessment tool, which adds GDF-15, Troponin T, and hemoglobin biological indicators to predict the risk of major bleeding events within 1 or 3 years.…”

Section: Discussionmentioning

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: Discussionmentioning

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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“…Baseline evaluation and management of bleeding risk, as well as the routine reevaluation during the clinical follow‐up, are pivotal for patients with AF to minimize occurring bleeding events 4, 5…”

Section: Introductionmentioning

confidence: 99%

Predicting Bleeding Events in Anticoagulated Patients With Atrial Fibrillation: A Comparison Between the HAS‐BLED and GARFIELD‐AF Bleeding Scores

Proietti

Rivera‐Caravaca

Esteve-Pastor

et al. 2018

JAHA

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BackgroundPatients with atrial fibrillation (AF) treated with oral anticoagulants may be exposed to an increased risk of bleeding events. The HAS‐BLED (Hypertension, Abnormal renal and liver function, Stroke, Bleeding, Labile INRs, Elderly, Drugs or alcohol) score is a simple, well‐established, clinical bleeding‐risk prediction score. Recently, a new algorithm‐based score was proposed, the GARFIELD‐AF (Global Anticoagulant in the Field–AF) bleeding score. We compared HAS‐BLED and GARFIELD‐AF scores in predicting adjudicated bleeding events in a clinical trial cohort of patients with AF taking anticoagulants, in the first external comparative validation of both scores.Methods and ResultsWe analyzed patients from the SPORTIF (Stroke Prevention Using an Oral Thrombin Inhibitor in Patients With AF) III and V trials. All patients assigned to the warfarin arm with information to calculate the scores were considered. Outcomes were major, major/clinically relevant nonmajor, and any bleeding. A total of 3550 warfarin‐treated patients were available for analysis. Of these patients, 2519 (71.0%) had a HAS‐BLED score ≥3, whereas based on GARFIELD‐AF median value, 2056 (57.9%) were categorized as “high score.” Both HAS‐BLED and GARFIELD‐AF C‐indexes showed modest predictive value (C‐index [95% confidence interval] for major bleeding, 0.58 [0.56–0.60] and 0.56 [0.54–0.57], respectively); however, GARFIELD‐AF was not predictive of any bleeding. The GARFIELD‐AF bleeding score had a significantly lower sensitivity and a negative reclassification for any bleeding compared with HAS‐BLED, assessed by integrated discrimination improvement and net reclassification improvement (both P<0.001). HAS‐BLED showed a 5% net benefit for any bleeding occurrence.ConclusionsThe algorithm‐based GARFIELD‐AF bleeding score did not show any significant improvement in major and major/clinically relevant nonmajor prediction compared with the simple HAS‐BLED score. For clinical usefulness in prediction of any bleeding, the HAS‐BLED score showed a significant net benefit compared with the GARFIELD‐AF.

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“…Finally, studies have often correlated stroke occurrences during long periods of follow-up to risk factors measured at baseline, and risk changes with increasing age and incident risk factors. Indeed, recent attention has been directed toward the dynamic nature of risk profiles in AF patients (176)(177)(178). Chao et al found the majority of patients with AF (89.4%) developed ≥1 new risk factor(s) prior to presenting with an ischemic stroke (178).…”

Section: Limitations Of Risk Scoresmentioning

confidence: 99%

Stroke and Bleeding Risk Assessments in Patients With Atrial Fibrillation: Concepts and Controversies

et al. 2020

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Incident Risk Factors and Major Bleeding in Patients with Atrial Fibrillation Treated with Oral Anticoagulants: A Comparison of Baseline, Follow-up and Delta HAS-BLED Scores with an Approach Focused on Modifiable Bleeding Risk Factors

Cited by 143 publications

References 18 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

Predicting Bleeding Events in Anticoagulated Patients With Atrial Fibrillation: A Comparison Between the HAS‐BLED and GARFIELD‐AF Bleeding Scores

Stroke and Bleeding Risk Assessments in Patients With Atrial Fibrillation: Concepts and Controversies

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