Bleeding risk scores in atrial fibrillation: helpful or harmful?


A number of different risk stratification scoring systems have been used to assess bleeding risk in atrial fibrillation (AF), including HAS-BLED (Hypertension, Abnormal renal and liver function, Stroke, Bleeding, Labile INR, Elderly, Drugs or alcohol), HEMORR2HAGES (History of bleeding, Hepatic or renal disease, Alcohol abuse, Malignancy, Older age, Reduced platelet count or function, Hypertension, Anemia, Genetic predisposition, Excessive fall risk, Stroke), ORBIT-AF (Outcomes Registry for Better Informed Treatment of Atrial Fibrillation), ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation), and more recently, GARFIELD-AF (Global Anticoagulant Registry in the Field – Atrial Fibrillation). Previously, HAS-BLED was found to be superior to the other scoring systems at determining clinically relevant bleeding risk. However, new evidence has suggested that the GARFIELD-AF risk model is superior to HAS-BLED for major bleeding. A further study (Proietti et al., discussed in this newsletter issue) sought to challenge this finding and found that GARFIELD-AF was not superior to HAS-BLED, for predicting any bleeding, in the SPORTIF patient populations.

While both studies were valid, different risk scoring systems provide different results depending on the patient population studied. Nevertheless, this editorial comment argues that none of the risk stratification scores are clinically impactful and that all patients should be monitored closely given the modest predictive value of bleeding risk scores. The authors suggest, therefore, that bleeding risk score serves only to allow exclusion of high-risk patients from potentially life-threatening therapy; a stance that is supported by the American Heart Association/American College of Cardiology/Heart Rhythm Society and European Society of Cardiology guidelines, which do not advocate their use in decision-making for antithrombotic therapy in AF.

Further investigations are required to establish the role of risk stratification in lower risk direct oral anticoagulant treatment settings, and data from randomized controlled trials assessing the use of bleeding risk scores to guide anticoagulation therapy are needed to support their use.

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Edmiston MK and Lewis WR. J Am Heart Assoc. 18 September, 2018;7:e010582. Epub ahead of print.