What is the comparison between the HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile International Normalized Ratio, Elderly, Drugs/Alcohol Concomitantly) score and the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines) score?

From the Guidelines

The HAS-BLED score is recommended for assessing bleeding risk in patients with atrial fibrillation, while the CRUSADE score is used for patients with acute coronary syndrome, as they serve different purposes and consider different factors. The HAS-BLED score considers factors like hypertension, abnormal renal/liver function, stroke history, bleeding history, labile INR, elderly age (>65), and drug/alcohol use, with a score of 3 or higher indicating high bleeding risk 1. In contrast, the CRUSADE score specifically assesses bleeding risk in patients with acute coronary syndrome who may undergo invasive procedures or receive antithrombotic therapy, incorporating baseline hematocrit, creatinine clearance, heart rate, sex, signs of heart failure, systolic blood pressure, and prior vascular disease 1.

When deciding which score to use, consider the patient's primary condition:

• Use HAS-BLED for atrial fibrillation patients needing anticoagulation, as it is predictive of bleeding in AF and non-AF cohorts, and in different ethnic groups, and is the only bleeding score predictive of intracranial bleeding 1.
• Use CRUSADE for acute coronary syndrome patients, as it has reasonable predictive value for major bleeding in ACS patients undergoing coronary angiography, and is the most discriminatory score for this purpose 1.

Both scores should inform clinical decisions but not replace clinical judgment, as they help balance the benefits of antithrombotic therapy against bleeding risks. It is essential to assess bleeding risk in patients with atrial fibrillation or acute coronary syndrome, as major bleeding events are associated with increased mortality in these patients 1.

Key factors to consider when using these scores include:

• Modifiable risk factors, such as uncontrolled hypertension, labile INR, and concomitant use of antiplatelet or nonsteroidal agents, which can elevate bleeding risk 1.
• The need for regular review and follow-up in patients with high bleeding risk, as identified by a HAS-BLED score ≥ 3 1.
• The importance of considering the patient's primary condition and using the appropriate score to inform clinical decisions 1.

From the Research

Comparison of HAS-BLED and CRUSADE Scores

• The HAS-BLED score is used to assess bleeding risk in patients with atrial fibrillation, and it has been shown to have moderate predictive abilities for bleeding risks in patients with AF regardless of type of oral anticoagulants 2.
• The CRUSADE score, on the other hand, is used to predict bleeding risk in patients with acute coronary syndromes, but there is no direct comparison between the two scores in the provided studies.
• However, the HAS-BLED score has been compared to other bleeding risk scores, such as the HEMORR2HAGES, ATRIA, ORBIT, GARFIELD-AF, CHADS2, and CHA2DS2-VASc scores, and it has been shown to have similar or superior predictive ability compared to these scores 2, 3.
• The GARFIELD-AF bleeding score, which is an algorithm-based score, did not show any significant improvement in major and major/clinically relevant nonmajor prediction compared to the simple HAS-BLED score 3.

Predictive Abilities of HAS-BLED Score

• The HAS-BLED score has been shown to be highly predictive for major bleeding events (HR, 2.04; 95% CI, 1.68-2.49; P<0.001) and adverse cardiovascular events (HR, 1.51; 95% CI, 1.27-1.81; P<0.001) in anticoagulated patients with AF 4.
• The score has also been shown to predict all-cause mortality (HR, 1.68; 95% CI, 1.40-2.01; P<0.001) in anticoagulated patients with AF 4.
• However, the score has been designed for predicting bleeding risk rather than thrombotic events per se, and specific risk scores for cardiovascular events and mortality should be applied for these events 4.

Clinical Implementation of HAS-BLED Score

• The HAS-BLED score can be used to identify patients at high risk for major bleeding during the initial treatment phase, while the VTE-BLEED score might be used to identify patients at low risk for bleeding and, therefore, to safely administer extended/long-term anticoagulation for secondary thromboprophylaxis 5.
• However, general clinical implementation of the HAS-BLED score cannot be recommended yet, as the scores demonstrated poor agreement and low to moderate discriminatory ability in predicting bleeding risk 6.