Summary
The HEMORR2HAGES score quantifies the risk of bleeding in patients with atrial fibrillation on anticoagulation and to aid in the management of antithrombotic therapy. The score combines hemorrhage risk factors from three clinical prediction rules. The HEMORR2HAGES score was validated by retrospectively applying it to a cohort of patients from the National Registry of Atrial Fibrillation database. A systematic review and meta-analysis comparing the performance of HAS-BLED, ATRIA and HEMORR2HAGES recommended HAS-BLED for the assessment of atrial fibrillation patients' major bleeding risk. However, the analysis found that HEMORR2HAGES had a higher diagnostic accuracy, but considered it difficult to use due its complexity. ScoringThe scoring system consists of eleven criteria, one of which (history of prior bleeding) is worth 2 points, while the other ten are worth 1 point each. CriteriaPointsHepatic or Renal Disease1Ethanol (Alcohol) Abuse1Malignancy history1Age (>75)1Reduced Platelet Count or Function1Rebleeding Risk2Hypertension (Uncontrolled)1Anemia1Genetic Factors1Excessive Fall Risk1Stroke History1 Results Major Bleed Event Risk ClassificationPointsRecommendationLow-risk0Risk of thrombotic events likely outweighs the risk of bleeding. Consider initiation of warfarin therapy (if clinically indicated).1.9% risk of bleeding per 100 patient-years of warfarinLow-risk1Risk of thrombotic events likely outweighs the risk of bleeding. Consider initiation of warfarin therapy (if clinically indicated).2.5% risk of bleeding per 100 patient-years of warfarinIntermediate-risk2Consider alternatives to anticoagulation unless strong indications for warfarin therapies exist. 5.3% risk of bleeding per 100 patient-years of warfarinIntermediate-risk3Consider alternatives to anticoagulation unless strong indications for warfarin therapies exist. 8.4% risk of bleeding per 100 patient-years of warfarinHigh-risk4Alternative options should often be considered when anticoagulation is indicated.10.4% risk of bleeding per 100 patient-years of warfarinHigh-risk5-12Alternative options should often be considered when anticoagulation is indicated.12.3% risk of bleeding per 100 patient-years of warfarin