What are the recommended calculators for assessing bleeding risk in patients?

Recommended Calculators for Assessing Bleeding Risk in Patients

The HAS-BLED score is the most strongly recommended calculator for assessing bleeding risk in patients, particularly for those with atrial fibrillation or on anticoagulation therapy. 1

Primary Bleeding Risk Assessment Tools

HAS-BLED Score

• Components: Hypertension, Abnormal renal/liver function (1 point each), Stroke history, Bleeding history or predisposition, Labile INR, Elderly (>65 years), Drugs/alcohol concomitantly (1 point each)
• Interpretation: Score ≥3 indicates high bleeding risk requiring more frequent monitoring
• Evidence base: Strongly recommended by CHEST guidelines for all patients with AF 1
• Clinical application: Focuses on modifiable risk factors that can be addressed to reduce bleeding risk

CRUSADE Score

• Primary use: Recommended for patients with acute coronary syndromes undergoing coronary angiography 1
• Components: Baseline hematocrit, creatinine clearance, heart rate, sex, signs of heart failure, prior vascular disease, diabetes mellitus, systolic blood pressure
• Advantages: Most discriminatory for major bleeding in ACS patients undergoing invasive procedures 1

ARC-HBR (Academic Research Consortium for High Bleeding Risk)

• Use case: Pragmatic approach for patients undergoing PCI 1
• Structure: Includes major criteria (anticipated long-term OAC, severe/end-stage CKD, hemoglobin <11 g/dL, spontaneous bleeding requiring hospitalization) and minor criteria (age ≥75, moderate CKD, mild anemia, spontaneous bleeding not requiring hospitalization)
• Interpretation: High bleeding risk if ≥1 major or ≥2 minor criteria are met 1

Algorithm for Selecting the Appropriate Bleeding Risk Calculator

1. Identify patient context:

   • Atrial fibrillation → Use HAS-BLED 1, 2
   • Acute coronary syndrome → Use CRUSADE 1
   • PCI procedure → Consider both PRECISE-DAPT and ARC-HBR 3, 4
   • Venous thromboembolism → Consider HAS-BLED, RIETE, or VTE-BLEED 5

2. Assess calculator performance for your specific patient population:

   • For AF patients: HAS-BLED outperforms other scores (HEMORR₂HAGES, ORBIT, ATRIA) 1
   • For ACS patients: CRUSADE shows better discrimination than other scores 1
   • For PCI patients: PRECISE-DAPT and ARC-HBR show similar predictive ability (AUC 0.61-0.62) 6

3. Consider timing of assessment:

   • Initial assessment → Focus on immediate bleeding risk factors
   • Long-term management → Reassess at every patient contact 1

Clinical Application of Bleeding Risk Assessment

• High HAS-BLED score (≥3):

  • Schedule more frequent follow-up (every 4 weeks rather than 4-6 months) 1, 2
  • Address modifiable risk factors (uncontrolled hypertension, labile INR, concomitant drugs/alcohol) 1
  • Do NOT withhold anticoagulation solely based on high bleeding risk score 2

• High CRUSADE score:

  • Consider radial access for coronary procedures 1
  • Adjust antithrombotic regimens 1
  • Monitor more closely during hospitalization 6

Important Caveats and Pitfalls

• Misusing scores to withhold therapy: A high bleeding risk score should prompt closer monitoring and risk factor modification, not withholding necessary anticoagulation 2

• Static assessment: Bleeding risk is dynamic and should be reassessed at every patient contact 1

• Overreliance on a single score: Different scores may perform better in specific populations - match the tool to the clinical context 3, 4

• Underestimation of risk: The PRECISE-DAPT score may underestimate bleeding risk (median absolute difference between observed and predicted 1-year risk: 1.1%) 4

• Dual risk consideration: Patients at high bleeding risk often also have high ischemic risk, requiring careful balance of therapies 4

By selecting the appropriate bleeding risk calculator and applying it correctly, clinicians can better identify patients requiring closer monitoring and targeted interventions to reduce bleeding complications while maintaining effective antithrombotic therapy.