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Direct-Acting Oral Anticoagulants (DOAC) Score

Predicts bleeding risk in patients with atrial fibrillation on DOAC.

CreatoreDr. Rahul Aggarwal, MD, FACC
Prova
Preferiti
Istruzioni

The DOAC Score is a bleeding risk prediction tool introduced in 2023, specifically developed for patients with atrial fibrillation (AF) who are being treated with (or considered for) direct-acting oral anticoagulants — dabigatran, rivaroxaban, apixaban, or edoxaban. It was developed because most current bleeding risk prediction tools for AF patients on oral anticoagulants were designed for warfarin, despite DOACs becoming an increasingly popular choice.

Development and Validation

The score was derived using a Cox proportional hazards model based on data from the RE-LY trial (dabigatran, n=5,684), then further refined using the GARFIELD-AF registry, which included dabigatran, edoxaban, rivaroxaban, and apixaban. It was validated across three large cohorts of individuals on DOACs. External validation was performed in the COMBINE-AF pooled clinical trial cohort and the Quebec RAMQ administrative database, with major bleeding as the primary outcome, and the score was directly compared against the HAS-BLED score. In the RE-LY cohort, 386 of 5,684 patients (6.8%) experienced a major bleeding event over a median follow-up of 1.74 years, and the model achieved an optimism-corrected C-statistic of 0.73 with good calibration. Notably, the DOAC Score showed stronger predictive performance than the HAS-BLED score.

Scoring Component

The DOAC score is calculated by adding the selected points for each variable:

Variable

Points

Age, years

<65

0

65-69

2

70-74

3

75-79

4

≥80

5

Creatinine clearance/estimated glomerular filtration rate (mL/min)

>60

0

30-60

1

<30

2

Underweight (body mass index <18.5 kg/m²)

No

0

Yes

1

Stroke/transient ischemic attack/embolism history

No

0

Yes

1

Diabetes

No

0

Yes

1

Hypertension

No

0

Yes

1

Antiplatelet use

No

0

Aspirin

2

Dual-antiplatelet

3

Nonsteroidal anti-inflammatory (NSAID) use

No

0

Yes

1

Bleeding history

No

0

Yes

3

Liver disease
(AST or ALT ≥3X upper limit of normal, ALP ≥2X upper limit of normal, or cirrhosis)

No

0

Yes

2

 

Results

Interpretation:

DOAC Score

1-Year Major Bleeding Risk

0-3

Very low

4-5

Low

6-7

Moderate

8-9

High

10*

Very high

* Individuals with scores ≥10 are assigned a score of 10.

Practical note: The DOAC Score is a decision-support tool intended to inform — not replace — clinical judgment when weighing bleeding risk against thromboembolic risk in individual patients.

 

Tutte le domande e i risultati possibili

Patient DetailsTitolo non visibile
Age

Select one option:

  • <65
  • 65-69
  • 70-74
  • 75-79
  • ≥80
Creatinine clearance/estimated glomerular filtration tate (ml/min)

Select one option:

  • > 60
  • 30-60
  • <30
Underweight

Select one option:

  • Yes
  • No
Stroke/transient ischemic attack/embolism history

Select one option:

  • Yes
  • No
Diabetes

Select one option:

  • Yes
  • No
Hypertension

Select one option:

  • Yes
  • No
Antiplatelet use

Select one option:

  • No
  • Aspirin
  • Dual-antiplatelet
Nonsteroidal anti-inflammatory (NSAID) use

Select one option:

  • Yes
  • No
Bleeding history

Select one option:

  • Yes
  • No
Liver disease

  • AST or ALT ≥3X upper limit of normal

  • ALP ≥2X upper limit of normal or

  • Cirrhosis

Select one option:

  • Yes
  • No
Risultati possibili
Very Low 1-Year Major Bleeding Risk

  • Clinical judgement and best practice guidelines (e.g. 2026 AHA Guideline for the Evaluation and Management of Acute PE in Adults) supersedes adjunct standalone decision tools.

  • Risk and benefits of anti-coagulation should be considered in patients, to include shared decsion-making and informed consent, prior to initiating therapy. 

  • Consider addressing modifiable risk factors for bleeding.

Moderate 1-Year Major Bleeding Risk

  • Clinical judgement and best practice guidelines (e.g. 2026 AHA Guideline for the Evaluation and Management of Acute PE in Adults) supersedes adjunct standalone decision tools.

  • Risk and benefits of anti-coagulation should be considered in patients, to include shared decsion-making and informed consent, prior to initiating therapy. 

  • Consider addressing modifiable risk factors for bleeding.

  • A high score is not necessarily a contraindication for DOAC therapy. Clinical context may be a driving factor.

Very High 1-Year Major Bleeding Risk

  • Clinical judgement and best practice guidelines (e.g. 2026 AHA Guideline for the Evaluation and Management of Acute PE in Adults) supersedes adjunct standalone decision tools.

  • Risk and benefits of anti-coagulation should be considered in patients, to include shared decsion-making and informed consent, prior to initiating therapy. 

  • Consider addressing modifiable risk factors for bleeding.

  • A high score is not necessarily a contraindication for DOAC therapy. Clinical context may be a driving factor.

Low 1-Year Major Bleeding Risk

  • Clinical judgement and best practice guidelines (e.g. 2026 AHA Guideline for the Evaluation and Management of Acute PE in Adults) supersedes adjunct standalone decision tools.

  • Risk and benefits of anti-coagulation should be considered in patients, to include shared decsion-making and informed consent, prior to initiating therapy. 

  • Consider addressing modifiable risk factors for bleeding.

High 1-Year Major Bleeding Risk

  • Clinical judgement and best practice guidelines (e.g. 2026 AHA Guideline for the Evaluation and Management of Acute PE in Adults) supersedes adjunct standalone decision tools.

  • Risk and benefits of anti-coagulation should be considered in patients, to include shared decsion-making and informed consent, prior to initiating therapy. 

  • Consider addressing modifiable risk factors for bleeding.

  • A high score is not necessarily a contraindication for DOAC therapy. Clinical context may be a driving factor.

Citazione

Aggarwal R, Ruff CT, Virdone S, Perreault S, Kakkar AK, Palazzolo MG, Dorais M, Kayani G, Singer DE, Secemsky E, Piccini J, Tahir UA, Shen C, Yeh RW. Development and Validation of the DOAC Score: A Novel Bleeding Risk Prediction Tool for Patients With Atrial Fibrillation on Direct-Acting Oral Anticoagulants. Circulation. 2023 Sep 19;148(12):936-946.

Letteratura

  • Development and Validation of the DOAC Score: A Novel Bleeding Risk Prediction Tool for Patients With Atrial Fibrillation on Direct-Acting Oral Anticoagulants

    Rahul Aggarwal 1 2, Christian T Ruff 3, Saverio Virdone 4, Sylvie Perreault 5, Ajay K Kakkar 4 6, Michael G Palazzolo 3, Marc Dorais 7, Gloria Kayani 4, Daniel E Singer 8, Eric Secemsky 1, Jonathan Piccini 9, Usman A Tahir 1, Changyu Shen 10, Robert W Yeh 1

    https://pubmed.ncbi.nlm.nih.gov/37621213/

  • Performance of HAS-BLED and DOAC scores to predict major bleeding events in atrial fibrillation patients treated with direct oral anticoagulants: A report from a prospective European observational registry

    Davide Antonio Mei 1, Jacopo Francesco Imberti 1, Niccolò Bonini 1, Giulio Francesco Romiti 2, Bernadette Corica 3, Marco Proietti 4, Marco Vitolo 1, Gregory Y H Lip 5, Giuseppe Boriani 6

    https://pubmed.ncbi.nlm.nih.gov/38969571/

  • Relative performance evaluation of four bleeding risk scores in atrial fibrillation patients. What does the new DOAC score provide?

    Emad Abu-Assi 1, Andrea Lizancos Castro 2, María Cespón-Fernández 2, Inmaculada González-Bermúdez 2, Sergio Raposeiras Roubin 3

    https://pubmed.ncbi.nlm.nih.gov/38579940/

  • Filling an Important Knowledge Gap: The DOAC Score

    Michael D Ezekowitz 1 2, Mohammed Kamareddine 3

    https://pubmed.ncbi.nlm.nih.gov/37621202/

  • Predictive performance of HAS-BLED, ORBIT, ABC, and DOAC scores for major bleeding in atrial fibrillation patients on DOACs

    Shan Zeng 1, Wengen Zhu 2, Siyu Guo 2, Hong Hong 3

    https://pubmed.ncbi.nlm.nih.gov/38969572/

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