How is the HASBLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile International Normalized Ratio, Elderly, Drugs/Alcohol Concomitantly) score used to guide anticoagulation therapy in patients with Atrial Fibrillation (AF) who have experienced an Intracranial Hemorrhage (ICH)?

HAS-BLED Score in Intracranial Hemorrhage and Atrial Fibrillation

The HAS-BLED score is strongly recommended for bleeding risk assessment in all AF patients, including those with prior ICH, to identify modifiable bleeding risk factors and guide anticoagulation decisions, but a high score (≥3) is rarely a reason to withhold anticoagulation therapy. 1

Understanding the HAS-BLED Score

The HAS-BLED score is a validated bleeding risk assessment tool that includes:

• Hypertension (systolic BP >160 mmHg) - 1 point 1
• Abnormal renal/liver function (1 point each) - 1-2 points 1
• Stroke history - 1 point 1
• Bleeding history or predisposition - 1 point 1
• Labile INRs (in patients taking VKAs) - 1 point 1
• Elderly (age >65 years) - 1 point 1
• Drugs/alcohol concomitantly (1 point each) - 1-2 points 1

Maximum score: 9 points

Role in Patients with AF and ICH

Risk Assessment Function

• HAS-BLED is the only bleeding score predictive of intracranial bleeding in AF patients 1
• It has been validated across multiple clinical settings including patients on no therapy, antiplatelet therapy, VKAs, or NOACs 1
• A score ≥3 indicates high bleeding risk requiring more frequent monitoring and follow-up 1
• In patients with prior ICH, the HAS-BLED score can help predict the risk of recurrent ICH 2

Clinical Application After ICH

1. Initial Assessment:

   • Calculate HAS-BLED score in all AF patients with ICH history 1
   • Focus on identifying modifiable bleeding risk factors 1
   • Higher scores correlate with increased risk of recurrent ICH (1.37,2.38,3.39, and 2.90 per 100 patient-years for scores of 1,2,3, and 4 respectively) 2

2. Decision Algorithm for Anticoagulation After ICH:

   • Assess stroke risk using CHA₂DS₂-VASc score 1
   • Calculate HAS-BLED score to identify modifiable risk factors 1
   • Address modifiable bleeding risks before considering anticoagulation 1
   • For patients requiring anticoagulation, consider DOACs over warfarin 3
   • Among DOACs, dabigatran 110mg appears to have the lowest ICH risk 4

Key Recommendations

• Do not withhold anticoagulation solely based on high HAS-BLED score - A high score (≥3) is rarely a reason to avoid anticoagulation 1
• Regular reassessment is essential - Bleeding risk is dynamic and should be formally reassessed at every patient contact 1
• Address modifiable risk factors - Focus on controlling hypertension, avoiding concomitant antiplatelet/NSAID use, limiting alcohol intake, and optimizing INR control in VKA users 1
• DOACs are preferred over VKAs - DOACs reduce ICH risk by nearly half compared to VKAs in AF patients 4, 3
• Consider specific DOACs for high-risk patients - For patients with AF who have experienced ICH, dabigatran 110mg may be the safest choice among DOACs 4

Timing of Anticoagulation Resumption After ICH

• In patients with AF presenting with acute ICH, anticoagulation should not be given in the presence of hemorrhage 1
• In the presence of a large cerebral infarction, delaying anticoagulation should be considered due to risk of hemorrhagic transformation 1
• Anticoagulation therapy should be considered approximately 2 weeks after stroke in the absence of hemorrhage 1

Common Pitfalls and Caveats

• Overemphasis on fall risk - The fear of falls may be overstated; a patient would need to fall approximately 300 times per year for the risk of ICH to outweigh the benefit of anticoagulation for stroke prevention 1
• Relying solely on modifiable risk factors - Simply depending on modifiable bleeding risk factors has suboptimal predictive value compared to using the complete HAS-BLED score 5
• Avoiding anticoagulation based only on bleeding risk - For most AF patients, the benefit of oral anticoagulation usually outweighs bleeding risk 1
• Failure to reassess regularly - Follow-up HAS-BLED scores are more predictive of major bleeding than baseline scores alone 1

The HAS-BLED score serves as a valuable tool to identify patients who require more careful monitoring and risk factor modification, not as a reason to withhold necessary anticoagulation therapy in AF patients with prior ICH 1.