Uncontrolled, >160 mmHg systolic
Dialysis, transplant, Cr >2.26 mg/dL or >200 μmol/L
Chronic hepatic disease or bilirubin >2x normal, AST/ALT/AP >3x normal
Unstable/high, time in therapeutic range <60%
Age >65
Antiplatelet agents, NSAIDs, alcohol abuse
HAS-BLED Score for Bleeding Risk Assessment
The HAS-BLED score is a clinical prediction rule used to estimate the risk of major bleeding in patients with atrial fibrillation who are receiving anticoagulation therapy. This score helps clinicians balance the benefits of stroke prevention against the risks of bleeding complications.
Scoring Criteria
The acronym HAS-BLED represents the key clinical risk factors, with 1 point assigned for each:
| Risk Factor | Points | Mnemonic |
|---|---|---|
| Hypertension (uncontrolled, >160 mmHg systolic) | +1 | H |
| Abnormal renal function (dialysis, transplant, Cr >2.26 mg/dL or >200 μmol/L) | +1 | A |
| Abnormal liver function (chronic hepatic disease or bilirubin >2x normal, AST/ALT/AP >3x normal) | +1 | S |
| Stroke (prior history) | +1 | B |
| Bleeding history or predisposition (anemia, bleeding diathesis) | +1 | L |
| Labile INRs (unstable/high, time in therapeutic range <60%) | +1 | E |
| Elderly (age >65) | +1 | D |
| Drugs/alcohol concomitantly (antiplatelet agents, NSAIDs, alcohol abuse) | +1 | D |
Note: The maximum possible score is 9.
Clinical Interpretation and Management
- Score 0-2: Low risk of major bleeding. Standard anticoagulation therapy is generally safe.
- Score 3-4: Moderate risk of major bleeding. Consider more frequent monitoring and patient education about bleeding risks.
- Score ≥5: High risk of major bleeding. Consider alternative strategies such as:
- More frequent INR monitoring
- Lower target INR range
- Consideration of left atrial appendage closure devices
- Enhanced patient education about bleeding symptoms
Important Clinical Considerations
The HAS-BLED score should not be used to withhold anticoagulation therapy in patients who otherwise qualify for it. Instead, it serves as a tool to:
- Identify modifiable risk factors for bleeding
- Guide the intensity of monitoring
- Inform patient education about bleeding risks
- Help in shared decision-making with patients
High HAS-BLED scores should prompt clinicians to address modifiable risk factors (e.g., uncontrolled hypertension, alcohol use, concomitant medications) rather than automatically discontinuing anticoagulation.
References
- Pisters, R., Lane, D. A., Nieuwlaat, R., de Vos, C. B., Crijns, H. J., & Lip, G. Y. (2010). A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest, 138(5), 1093-1100.
- Lip, G. Y., Frison, L., Halperin, J. L., & Lane, D. A. (2011). Comparative validation of a novel risk score for predicting bleeding risk in anticoagulated patients with atrial fibrillation: the HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly) score. Journal of the American College of Cardiology, 57(2), 173-180.
- January, C. T., Wann, L. S., Calkins, H., Chen, L. Y., Cigarroa, J. E., Cleveland, J. C., ... & Yancy, C. W. (2019). 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Journal of the American College of Cardiology, 74(1), 104-132.
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