Arrhythmias and Conduction Disturbances
Comparison of HAS-BLED and HAS-BED Versus CHADS2 and CHA2DS2VASC Stroke and Bleeding Scores in Patients With Atrial Fibrillation

https://doi.org/10.1016/j.amjcard.2016.12.007Get rights and content

Anticoagulation is recommended in patients with atrial fibrillation (AF) for stroke prevention, and the bleeding risk associated suggests the need for a bleeding risk stratification. HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio (INR), elderly >65 years, drugs/alcohol concomitantly) score includes “labile INR” referred to quality of anticoagulation. However, in naïve patients, this item is not available. In addition, stroke and bleeding risk prediction scores shared several risk factors. The aims of our study were as follows: (1) to evaluate if the HAS-BLED score in its refined form excluding “labile INR” (HAS-BED [hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, elderly, drugs/alcohol]) is still associated with bleeding risk and (2) to evaluate the predictive ability for bleeding of both stroke and bleeding prediction models. We followed an inception cohort of 4,579 patients with AF enrolled in the Survey on anticoagulaTed pAtients RegisTer (NCT02219984). Major bleeds were recorded. During follow-up (7,014 patient-years), 115 patients experienced a major bleeding (MB; rate 1.6 × 100 patient-years). Patients at high risk were better identified by HAS-BLED and HAS-BED scores with respect to CHADS2 (congestive heart failure, hypertension, age >75 years, diabetes, previous stroke or transient ischemic attack) and CHA2DS2VASc (congestive heart, failure, hypertension, age [>75 years], diabetes, stroke/transient ischemic attack, vascular disease, age [65 to 74 years], female gender). HAS-BLED has a slightly higher c value in comparison to CHADS2 and CHA2DS2VASc. However, among naïve patients, the predictive ability for hemorrhage of HAS-BED score is overlapping with CHADS2 and CHA2DS2VASc. In low stroke risk patients (CHA2DS2VASc = 0 to 1), only 6 patients are at high bleeding risk, and none of them experienced MB. In conclusion, in our prospective cohort of patients with AF, we found that HAS-BLED and HAS-BED scores identify patients at high bleeding risk. However, the predictive value for MB of HAS-BED used in naïve patients is similar to CHADS2 or CHA2DS2VASc, suggesting that stroke stratification scores could be sufficient for tailoring treatment.

Section snippets

Methods

The START register is an observational, multicenter, prospective cohort study that includes adults (>18 years) who start anticoagulation therapy, whatever the clinical indication for the therapy, the drug and dosage used.7 The aim of the START register is to collect data on effectiveness and safety of anticoagulant treatments, on determinants of adverse events in anticoagulated patients, as well as on their quality of life and compliance to treatment. The register has been approved on October

Results

We followed an inception cohort of 4,579 patients with AF starting anticoagulation and enrolled in the START register, patients characteristics are listed in Table 1. The distribution of patients according to stroke and bleeding risk scores is reported in Table 2. During follow-up, 115 patients experienced a MB events (rate 1.6 × 100 pt-yrs), and 13 hemorrhages (11.3%, rate 0.2 × 100 pt-yrs) were fatal. The distribution of MBs in relation to the considered scores is reported in Table 3 (as

Discussion

Our study confirms that HAS-BLED score is useful to identify patients at high risk for bleeding,11 even when HAS-BED is applied in naïve patients. In addition, the stroke predictive models CHADS2 and CHA2DS2-VASc scores are able to identify patients at high risk for bleeding, even if HAS-BLED and HAS-BED scores perform better for that purpose. However, as expected, the predictive ability for bleeding risk is modest for all the scores and among naïve patients is similar for both bleeding and

Disclosures

The authors have no conflicts of interest to disclose.

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