A Standardized Bleeding Risk Score Aligns Anticoagulation Choices with Current Evidence

Berger, Arielle S. MD*; Dunn, Andrew S. MD, MPH; Kelley, Amy S. MD, MSHS‡,§

Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine:
doi: 10.1097/HPC.0000000000000017
Original Articles
Abstract

Objectives: Atrial fibrillation (AF), the most common arrhythmia in elderly patients, accounts for 15% of strokes. Oral anticoagulation (OAC) can reduce the risk of stroke by 60% but is underprescribed. The HAS-BLED score (Hypertension, Abnormal renal or liver function, Stroke, Bleeding, Labile INR, Elderly, Drugs) can predict OAC bleeding complications. The authors hypothesized that use of HAS-BLED can help align decision making with current evidence.

Methods: The authors developed a survey with four clinical vignettes designed to highlight the complexity in deciding whether to anticoagulate elderly patients with AF. Physicians were randomly assigned to receive the survey either including the HAS-BLED score and the estimated annual risk of bleeding (intervention) or without (control). Following each vignette, participants were asked: (1) whether they would recommend OAC and (2) to estimate the risk of bleeding and stroke. The “appropriate” anticoagulation decision was defined as the choice that minimized the risk of stroke and major bleeding.

Results: A total of 203 physicians were recruited for the survey, with 55 responses obtained (27%). Physicians who were given the HAS-BLED score were 18% more likely to choose appropriate anticoagulation (74% vs. 56%, P < .05). The HAS-BLED score assisted physicians in both choosing to anticoagulate when appropriate and not to anticoagulate when the risk of bleeding outweighed the benefit. Overall, physicians were poor at estimating the risk of stroke (42% correct) and major bleeding (31% correct).

Conclusions: Presentation of the HAS-BLED score led to an 18% improvement in appropriate OAC choices. Future study should evaluate incorporation of HAS-BLED use in real-time clinical situations.

Author Information

From the *Department of Medicine, Mount Sinai and University Health Network Hospitals, Toronto, ON, Canada; Department of Medicine, Mount Sinai Hospital, New York,NY; Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; and §Geriatric Research Education and Clinical Centers, James J Peters VA Medical Center, Bronx, New York, NY

This work was presented in poster form at the American Geriatrics Society Annual Scientific Meeting in Grapevine, Texas on May 3, 2013.

Reprints: Arielle S. Berger, MD, 550 University Avenue, 5–113, Toronto, ON M5G 2A2, Canada. E-mail: arielle.berger@uhn.ca

This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

© 2014 by Lippincott Williams & Wilkins