HAS-BLED Score for Major Bleeding Risk

Why did you develop the HAS-BLED score? Was there a clinical experience that inspired you to create this tool for clinicians?

Increasing awareness of the evidence that oral anticoagulation is a necessity in the vast majority of atrial fibrillation (AF) patients, outdated paradigms to withhold anticoagulation (e.g. fall risk) and a lacking user-friendly counterpart to stroke risk assessment (e.g. CHA₂DS₂-VASc) despite the inherent (antithrombotic drug related) risk of bleeding led us to develop the HAS-BLED score.

What pearls, pitfalls and/or tips do you have for users of the HAS-BLED score? Are there cases when it has been applied, interpreted, or used inappropriately?

The most important pitfall is using HAS-BLED as an absolute cut-off to withhold or withdraw anticoagulation. Keep in mind that in the vast majority of AF patients risk of stroke (and associated outcome) outweighs risk of bleeding. Instead, HAS-BLED should be used as an alarmbell which assists in minimizing the potential risk of bleeding by signaling risk factors that can be avoided or reversed. Both important to note and as a good example of the alarmbell function is that the ”H” in HAS-BLED (opposed to the stroke risk equivalent) does not stand for history of hypertension but refers to the actual systolic blood pressure (≥160 mmHg scores 1 point). Thus, explain the importance of blood pressure control and actively lower it accordingly to reverse it as risk factor for major bleeding, i.e. lose 1 HAS-BLED point and lower the bleeding risk (whereas the risk of stroke remains the same!).

What recommendations do you have for health care providers once they have the HAS-BLED score result? Are there any adjustments or updates you would make to the score given recent changes in medicine?

Antithrombotic management is not about a single, simple decision to initiate antithrombotic drugs or not. Antithrombotic management is all about the continuous balancing of risk (assessment) and communication. HAS-BLED is an easy-to-use tool capable of both when it comes to the risk of major bleeding of your AF patients.

Ron Pisters, MD, PhD, is a cardiologist at Rijnstate Ziekenhuis Arnhem in the Netherlands. Previously, he worked as a clinical research fellow, focusing on atrial fibrillation, under the supervision of Harry JGM Crijns at the Department of Cardiology, University of Maastricht. Dr. Pisters' research interests include antithrombotic management of patients with atrial fibrillation and assessing the individualised risk of embolic and bleeding events.