Scoring Systems for Estimating the Risk of Anticoagulant-Associated Bleeding

Abstract

Anticoagulant medications are frequently used to prevent and treat thromboembolic disease. However, the benefits of anticoagulants must be balanced with a careful assessment of the risk of bleeding complications that can ensue from their use. Several bleeding risk scores are available, including the Outpatient Bleeding Risk Index, HAS-BLED, ATRIA, and HEMORRHAGES risk assessment tools, and can be used to help estimate patients' risk for bleeding on anticoagulants. These tools vary by their individual risk components and in how they define and weigh clinical factors. However, it is not yet clear how best to integrate bleeding risk tools into clinical practice. Current bleeding risk scores generally have modest predictive ability and limited ability to predict the most devastating complication of anticoagulation, intracranial hemorrhage. In clinical practice, bleeding risk tools should be paired with a formal determination of thrombosis risk, as their results may be most influential for patients at the lower end of thrombosis risk, as well as for highlighting potentially modifiable risk factors for bleeding. Use of bleeding risk scores may assist clinicians and patients in making informed and individualized anticoagulation decisions.

Risk Stratification for Bleeding Complications in Patients With Venous Thromboembolism: Application of the HAS‐BLED Bleeding Score During the First 6 Months of Anticoagulant Treatment

“…Validating an existing risk stratification tool like HAS‐BLED across multiple indications may help improve clinical adoption and encourage its uptake in practice . Some urge caution in applying bleeding risk scores in the clinical environment, due to the development of these scores based on initial clinical decisions to prescribe anticoagulants which necessitated that the patients were considered lower bleed risk . Additionally, bleed risk scores have only been modestly predictive of bleeding in anticoagulated patients with VTE in a prior validation study .…”

“…Also, there is the perception that bleeding risk scores are inappropriately used to deny patients anticoagulation because of their perceived “high risk” although bleeding risk is highly dynamic and modifiable, and the reversible risk factors for bleeding should be addressed in all patients rather than just those at high risk . HAS‐BLED has been used widely in clinical and research settings, and performs better than other bleeding risk scores (including ATRIA) . HAS‐BLED should be compared with other bleed scores specifically developed in the VTE population to determine the comparative predictive validity of these similar clinical tools.…”

“…19 Some urge caution in applying bleeding risk scores in the clinical environment, due to the development of these scores based on initial clinical decisions to prescribe anticoagulants which necessitated that the patients were considered lower bleed risk. 20 Additionally, bleed risk scores have only been modestly predictive of bleeding in anticoagulated patients with VTE in a prior validation study. 21 Also, there is the perception that bleeding risk scores are inappropriately used to deny patients anticoagulation because of their perceived "high risk" although bleeding risk is highly dynamic and modifiable, and the reversible risk factors for bleeding should be addressed in all patients rather than just those at high risk.…”

The American College of Chest Physician score to assess the risk of bleeding during anticoagulation in patients with venous thromboembolism: reply

“…We share some final messages conveyed by Brown et al The decision regarding the duration of anticoagulation after a VTE episode should include assessment of the individual risk of recurrence, possibly by use of a clinical prediction rule and/or other tools (such as D-dimer testing). Estimating the individual risk of anticoagulationassociated bleeding appears to be more difficult, because the currently available scores have only limited predictive ability [7,8], and have not included, so far, patients receiving long-term treatment with low-dose DOACs. Furthermore, the effect of the identification and management of any potentially modifiable risk factor for bleeding during anticoagulant treatment should also be assessed.…”

The American College of Chest Physician score to assess the risk of bleeding during anticoagulation in patients with venous thromboembolism: comment

“…Some urge caution in applying bleeding risk scores in the clinical environment, because of the development of these scores based on initial clinical decisions to prescribe anticoagulants, which necessitated that the patients were considered to have a lower risk of bleeding [9]. There is also the perception that bleeding risk scores are inappropriately used to deny patients anticoagulation because of their perceived 'high risk', although bleeding risk is highly dynamic and modifiable, and the reversible risk factors for bleeding should be addressed in all patients rather than just those at high risk [10].…”