The HAS‐BLED Score for Predicting Major Bleeding Risk in Anticoagulated Patients With Atrial Fibrillation: A Systematic Review and Meta‐analysis

Abstract

Our objective was to compare the diagnostic accuracy between the HAS-BLED score and any of HEMORR2 HAGES, ATRIA, CHADS2 , or CHA2 DS2 -VASc scores in anticoagulated patients with atrial fibrillation. We systematically searched the Cochrane Library, MEDLINE, PubMed, and Embase databases for relevant studies. Data were extracted and analyzed according to predefined clinical endpoints. Eleven studies were identified. Discrimination analysis demonstrates that HAS-BLED has no significant C-statistic differences for bleeding risk prediction compared with ATRIA or HEMORR2 HAGES, but it has significant differences compared with CHADS2 or CHA2 DS2 -VASc. The significant positive net reclassification improvement and integrated discrimination improvement values also show that HAS-BLED is superior to that of any of HEMORR2 HAGES, ATRIA, CHADS2 , or CHA2 DS2 -VASc scores. According to calibration analysis of HAS-BLED, it overpredicts the risk of bleeding in the low (risk ratio [RR]: 1.16, 95% confidence interval [CI]: 0.63-2.13, P = 0.64) risk stratification but underpredicts that in the moderate (RR: 0.66, 95% CI: 0.51-0.86, P = 0.002) and high (RR: 0.88, 95% CI: 0.70-1.10, P = 0.27) risk stratifications. The HAS-BLED score not only performs better than the HEMORR2 HAGES and ATRIA bleeding scores, but it also is superior to the CHADS2 and CHA2 DS2 -VASc stroke scores for bleeding prediction. The HAS-BLED score should be the optimal choice to assess major bleeding risk in clinical practice.

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

“…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.…”

National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the diagnosis and management of atrial fibrillation 2018

“…GRADE: Strong; Evidence: Low. ► Practice point : Patients at high risk of stroke are also at high risk of major bleeding 37 . The net clinical benefit almost always favours stroke prevention over major bleeding, so bleeding risk scores should not be used to avoid anticoagulation in patients with AF.…”

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

“…Another study compared HAS‐BLED's accuracy to those of ATRIA, HEMORR2HAGES, CHADS2, and CHA2DS2‐VASc in predicting bleeding. Significant positive net reclassification improvement and integrated discrimination improvement values showed HAS‐BLED was superior to the other scores . HAS‐BLED's sensitivity and specificity were also compared to those of ATRIA and HEMORR2HAGES, revealing that neither of the two methods was sensitive enough .…”