What scoring system is used to determine the risk of bleeding in a patient with atrial fibrillation (AFib) and a history of gastrointestinal (GI) bleed?

HAS-BLED Score for Bleeding Risk Assessment in AFib with Prior GI Bleed

Use the HAS-BLED score to determine bleeding risk in patients with atrial fibrillation and a history of gastrointestinal bleeding. This is the recommended scoring system according to the 2018 CHEST guidelines, which provide a strong recommendation with moderate quality evidence for its use in all AF patients requiring bleeding risk assessment 1.

Why HAS-BLED is the Preferred Score

The HAS-BLED score outperforms alternative bleeding risk scores in multiple ways:

• Superior sensitivity and ease of application compared to HEMORR2HAGES, ATRIA, ORBIT, and ABC-bleeding scores for assessing major bleeding risk in AF patients 1.
• Only bleeding score predictive of intracranial bleeding, which is particularly important given the catastrophic nature of this complication 1.
• Validated across all anticoagulation scenarios including patients on no antithrombotic therapy, aspirin, vitamin K antagonists (VKAs), and direct oral anticoagulants (DOACs) 1.
• Better at identifying low-risk patients compared to the ABC-bleeding score in real-world AF cohorts 1.

HAS-BLED Score Components

The score ranges from 0-9 points, with one point assigned for each of the following 2:

• Hypertension (uncontrolled, systolic BP >160 mmHg)
• Abnormal renal function (dialysis, transplant, or creatinine >2.26 mg/dL) OR abnormal liver function (cirrhosis or bilirubin >2x normal or AST/ALT/ALP >3x normal) - 1 point each
• Stroke history
• Bleeding history or predisposition (prior major bleed, anemia, or bleeding diathesis) - this is where your patient's GI bleed history counts
• Labile INR (time in therapeutic range <60% if on warfarin)
• Elderly (age >65 years)
• Drugs (concomitant antiplatelet agents or NSAIDs) OR alcohol (≥8 drinks/week) - 1 point each

Score Interpretation and Clinical Action

HAS-BLED ≥3 defines high bleeding risk but this should trigger intensified management, NOT anticoagulation avoidance 1, 2:

• Score 0-2 (Low-Moderate Risk): Proceed with standard anticoagulation and routine follow-up 3.
• Score ≥3 (High Risk): Implement more frequent reviews (every 4 weeks rather than 4-6 months) and aggressively address modifiable risk factors 1, 3.

Critical Management Principle for Your Patient

A history of GI bleeding automatically gives your patient at least 1 point on HAS-BLED, but this is NOT a contraindication to anticoagulation 1, 3. The CHEST guidelines explicitly state that a high HAS-BLED score (≥3) is rarely a reason to avoid anticoagulation, as the net clinical benefit is even greater in high-risk patients 1, 4.

Addressing Modifiable Risk Factors

For patients with prior GI bleeding, focus on these modifiable components 1, 2:

• Optimize blood pressure to <160 mmHg systolic
• Discontinue NSAIDs and aspirin unless absolutely necessary for another indication
• Treat underlying GI pathology (e.g., eradicate H. pylori, treat peptic ulcers, manage varices)
• Reduce alcohol consumption if excessive
• Optimize renal and liver function where possible
• If on warfarin with labile INR, consider switching to a DOAC or increase monitoring frequency

Anticoagulant Selection in High Bleeding Risk

Prefer DOACs over warfarin in patients with HAS-BLED ≥3, particularly 3, 4:

• Apixaban (lowest major bleeding rates in trials)
• Dabigatran 110 mg BID (reduced dose, lower bleeding than warfarin)
• Edoxaban (lower bleeding than warfarin)

These agents demonstrate significantly less major bleeding compared to warfarin in patients with prior bleeding history 3, 4.

Dynamic Reassessment is Essential

Bleeding risk is highly dynamic and must be reassessed at every patient contact 1. The "delta HAS-BLED score" (change over time) is more predictive of major bleeding than the baseline score alone 1.

Common Pitfalls to Avoid

• Never withhold anticoagulation solely because of a high HAS-BLED score - the score identifies who needs closer monitoring, not who should be denied therapy 1, 3.
• Do not use HAS-BLED as a static, one-time assessment - recalculate at each visit as clinical factors change 1.
• Do not substitute aspirin for anticoagulation in high bleeding risk patients - aspirin provides inadequate stroke protection and has similar bleeding risk to anticoagulation in AF 4.
• Do not ignore the "bleeding predisposition" component - prior GI bleeding qualifies and should be counted 2.