Bleeding risk assessment for outpatients on warfarin

Outpatient Bleeding Risk Index

Beyth RJ, Quinn LM, Landefeld CS. Prospective evaluation of an index for predicting major bleeding in outpatients treated with warfarin. Am J Med. 1998;105:91-9.

Aspinall SL, DeSanzo BE, Trilli LE, et al. Bleeding Risk Index in an anticoagulation clinic. Assessment by indication and implications for care. J Gen Intern Med. 2005;20:1008-13.

Risk Factor Points Awarded
Age >= 65 1
History of stroke 1
History of gastrointestinal bleeding 1
Presence of 1 or more comorbid conditions
(recent MI; SCr > 1.5mg/dL; Hct < 30%; diabetes)
1

Bleeding Risk Group Observed Outpatient Risk of Major Bleeding Observed Outpatient Risk of Minor Bleeding
0 points =
Low Risk
0.8 %/pt-yr 8.5%/pt-yr
1-2 points = Intermediate Risk 2.6 %/pt-yr 5.3 %/pt-yr
3-4 points =
High Risk
9.7 %/pt-yr 6.1 %/pt-yr

 

HEMORR2HAGES

Gage BF, Yan Y Milligan PE, et al. Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillatiion. Am Heart J 2006; 151:713-9.

Letter Clinical Characteristic Points Awarded
H Hepatic or renal disease 1
E Ethanol abuse 1
M Malignancy 1
O Older age (>75) 1
R Reduced platelet count or function 1
R Rebleeding risk (ie: prior bleed) 2
H Hypertension, uncontrolled 1
A Anemia 1
G Genetic factors (CYP2C9 variant) 1
E Excessive fall risk 1
S Stroke 1

Risk Score Incidence of Major Bleeding (%/pt-yr)
0 1.9
1 2.5
2 5.3
3 8.4
4 10.4
>=5 12.3

 

The HAS-BLED Score

Pisters R, Lane DA, Nieuwlaat R, deVos CB, Crijns HJGM, Lip GYH. 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 2010; 138:1093-1100

Letter Clinical Characteristic Definition Points Awarded
H Hypertension Uncontrolled; >160mmHg systolic 1
A Abnormal renal and/or liver function (1 point each) Renal: chronic dialysis, renal transplant, or Scr> 2
Liver: chronic hepatic disease or laboratory evidence
1 or 2
S Stroke Prior history of stroke 1
B Bleeding Bleeding histor, anemia, or predisposition to bleeding 1
L Labile INRs Therapeutic time-in-range < 60% 1
E Elderly Age > 65 1
D Drugs and/or alcohol Drugs: concurrent antiplatelet agents or NSAIDS
Alcohol: 8 or more drinks per week
1 or 2
Risk Score Incidence of Major Bleeding In Euro Heart Survey Patients (%/pt-yr)
0 1.13
1 1.02
2 1.88
3 3.74
4 8.7
5 12.5
6 0 bleeds/2 patients
7 0 patients
8 0 patients
9 0 patients