23 Bleeding Risk Scores in AF ATRIAHAS-BLED HEMORR 2 HAGES Anemia 1 3 H ypertension 4 1 H epatic 10 or Renal disease 2 1111 Severe renal disease 2 3 A bnormal Renal 5 or Liver function 6 1111 E thanol abuse 1 Age ≥75 yrs2 S troke 1 M alignancy 1 Any prior hemorrhage1 B leeding 1 O lder Age (>75 yrs) 1 Hypertension 3 1 L abile INR 8 1 R educed platelet number or function 11 1 E lderly (>65 yrs) 1 R ebleeding 12 2 D rugs 9 or Alcohol 1111 H ypertension 4 1 A nemia 13 1 G enetic factors 14 1 E xcessive fall risk 15 1 S troke 1 Apostolakis S, Lane DA, Guo Y, Buller H, Lip GY.
{"Image DocumentName": "Bleeding Risk Scores in AF", "Image ImageDescription": "ATRIA. HAS-BLED. HEMORR2HAGES. Anemia1. 3. Hypertension4. 1. Hepatic10 or. Renal disease2. Severe renal disease2. Abnormal Renal5 or Liver function6. Ethanol abuse. Age \u226575 yrs. 2. Stroke. Malignancy. Any prior hemorrhage. Bleeding. Older Age (>75 yrs) Hypertension3. Labile INR8. Reduced platelet number or function11. Elderly (>65 yrs) Rebleeding12. Drugs9 or Alcohol. Anemia13. Genetic factors14. Excessive fall risk15. SOURCE GIVEN IN ORIGINAL SLIDE SET: Apostolakis S, Lane DA, Guo Y, Buller H, Lip GY. J Am Coll Cardiol Jul 24. [Epub ahead of print] PMID: Am Coll Cardiol Jul 24. [Epub ahead of print] Performance of the HEMORR(2)HAGES, ATRIA, and HAS-BLED Bleeding Risk-Prediction Scores in Patients With Atrial Fibrillation Undergoing Anticoagulation: The AMADEUS (Evaluating the Use of SR34006 Compared to Warfarin or Acenocoumarol in Patients With Atrial Fibrillation) Study. Apostolakis S, Lane DA, Guo Y, Buller H, Lip GY. Source University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom. OBJECTIVES:The objective of this study was to compare the predictive performance of bleeding risk-estimation tools in a cohort of patients with atrial fibrillation (AF) undergoing anticoagulation. BACKGROUND:Three bleeding risk-prediction schemes have been derived for and validated in patients with AF: HEMORR(2)HAGES (Hepatic or Renal Disease, Ethanol Abuse, Malignancy, Older Age, Reduced Platelet Count or Function, Re-Bleeding, Hypertension, Anemia, Genetic Factors, Excessive Fall Risk and Stroke), ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation), and HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile International Normalized Ratio, Elderly, Drugs/Alcohol). \u03a4he relative predictive values of these bleeding scores have not previously been compared. METHODS:We analyzed the dataset from the AMADEUS (Evaluating the Use of SR34006 Compared to Warfarin or Acenocoumarol in Patients With Atrial Fibrillation) trial, a multicenter, randomized, open-label noninferiority study that compared fixed-dose idraparinux with adjustable-dose oral vitamin K antagonist therapy in patients with AF. The principal safety outcome was any clinically relevant bleeding event, which was a composite of major bleeding plus clinically relevant nonmajor bleeding. RESULTS:The HAS-BLED score performed best in predicting any clinically relevant bleeding, reflected both in net reclassification improvement (10.3% and 13% improvement compared with HEMORR(2)HAGES and ATRIA, respectively) and receiver-operating characteristic (ROC) analyses (c-indexes: 0.60 vs and 0.50 for HAS-BLED vs. HEMORR(2)AGES and ATRIA, respectively). Using decision-curve analysis, the HAS-BLED score demonstrated superior performance compared with ATRIA and HEMORR(2)HAGES at any threshold probability for clinically relevant bleeding. HAS-BLED was the only score that demonstrated a significant predictive performance for intracranial hemorrhage (c-index: 0.75; p = 0.03). An ATRIA score >3 was not significantly associated with the risk for any clinically relevant bleeding on Cox regression or on ROC analysis (c-index: 0.50; p = 0.87). CONCLUSIONS: All 3 tested bleeding risk-prediction scores demonstrated only modest performance in predicting any clinically relevant bleeding, although the HAS-BLED score performed better than the HEMORR(2)HAGES and ATRIA scores, as reflected by ROC analysis, reclassification analysis, and decision-curve analysis. Only HAS-BLED demonstrated a significant predictive performance for intracranial hemorrhage. Given its simplicity, the HAS-BLED score may be an attractive method for the estimation of oral anticoagulant-related bleeding risk for use in clinical practice, supporting recommendations in international guidelines. Copyright \u00a9 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved. Hemoglobin <13 g/dl men; <12 g/dl women. Estimated glomerular filtration rate <30 ml/min or dialysis-dependent. Diagnosed hypertension. Systolic blood pressure >160 mmHg. Presence of chronic dialysis or renal transplantation or serum creatinine \u2265200 mmol/L. Chronic hepatic disease (eg cirrhosis) or biochemical evidence of significant hepatic derangement (eg bilirubin 2 x upper limit of normal, in association with aspartate aminotransferase/alanine aminotransferase/alkaline phosphatase >3 x upper limit normal, etc.) Unstable/high INRs or poor time in therapeutic range (eg <60%) Concomitant use of drugs, such as antiplatelet agents, non-steroidal anti-inflammatory drugs, or alcohol abuse etc. Cirrhosis, two-fold or greater elevation of AST or APT, or albumin <3.6 g/dl. Platelets <75,000, use of antiplatelet therapy (eg daily aspirin) or NSAID therapy; or blood dyscrasia. Prior hospitalization for bleeding. Most recent hematocrit <30 or hemoglobin <10 g/dl. CYP2C9 2 and/or CYP2C9 3. Alzheimer s dementia, Parkinson s disease, schizophrenia, or any condition predisposing to repeated falls. Apostolakis S, Lane DA, Guo Y, Buller H, Lip GY. J Am Coll Cardiol 2012;60:000\u2013 Jul 24. [Epub ahead of print] Online Appendix. 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