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HAS‑BLED Score for Bleeding Risk in Atrial Fibrillation
The HAS‑BLED score is a validated clinical tool used to estimate the 1-year risk of major bleeding in patients with atrial fibrillation (AF) undergoing anticoagulation. Developed by Pisters et al. in 2010, the acronym represents the primary variables it assesses: hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile INR, elderly, and Drug/alcohol use. This risk model supports decisions around anticoagulation therapy by identifying patients at elevated risk of bleeding events.
The HAS‑BLED calculator is widely implemented in both outpatient and inpatient settings. It is often integrated into electronic health records or used through point-of-care tools. While it does not dictate treatment, the score helps guide how aggressively modifiable bleeding risks should be addressed and whether enhanced monitoring is warranted. For patients with a score of 3 or higher, the risk of bleeding is considered elevated, prompting closer evaluation and, when necessary, modification of treatment plans.
Despite its limitations, the HAS‑BLED score remains a commonly used adjunct in the anticoagulation management of AF patients. It is most effective when interpreted in the context of broader clinical judgment and individualized risk-benefit assessment.
HAS‑BLED Score Calculator
Hypertension
Systolic blood pressure greater than 160 mmHg.
Renal disease
Includes dialysis, kidney transplant, or serum creatinine greater than 2.26 mg/dL (200 µmol/L).
Liver disease
Defined as cirrhosis or biochemical evidence such as bilirubin over 2 times normal with AST, ALT, or alkaline phosphatase over 3 times normal.
Stroke
History of ischemic or hemorrhagic stroke.
Bleeding
Prior major bleeding or known bleeding predisposition.
Labile INR
Unstable or high INRs with time in therapeutic range below 60%.
Elderly
Age over 65 years.
Drugs
Use of medications that increase bleeding risk, such as aspirin, clopidogrel, or NSAIDs.
Alcohol
Consumption of 8 or more alcoholic drinks per week.
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HAS-BLED Score Components and Risk Stratification
The HAS-BLED score assigns one point for each of the following clinical factors:
• Hypertension: Systolic blood pressure greater than 160 mmHg.
• Renal disease: Includes dialysis, kidney transplant, or serum creatinine greater than 2.26 mg/dL (200 µmol/L).
• Liver disease: Defined as cirrhosis or biochemical evidence such as bilirubin over 2 times normal with AST, ALT, or alkaline phosphatase over 3 times normal.
• Stroke: History of ischemic or hemorrhagic stroke.
• Bleeding: Prior major bleeding or known bleeding predisposition.
• Labile INR: Unstable or high INRs with time in therapeutic range below 60%.
• Elderly: Age over 65 years.
• Drugs: Use of medications that increase bleeding risk, such as aspirin, clopidogrel, or NSAIDs.
• Alcohol: Consumption of 8 or more alcoholic drinks per week.
HAS-BLED Scoring
0: Low risk group, risk of major bleeding 0.9%, bleeds per 100 patient years 1.13, recommendation of anticoagulation should be considered.
1: Low risk group, risk of major bleeding 3.4%, bleeds per 100 patient years 1.02, recommendation of anticoagulation should be considered.
2: Moderate risk group, risk of major bleeding 4.1%, bleeds per 100 patient years 1.88, recommendation of anticoagulation can be considered.
3: High risk group, risk of major bleeding 5.8%, bleeds per 100 patient years 3.72, recommendation of alternatives to anticoagulation should be considered.
4: High risk group, risk of major bleeding 8.9%, bleeds per 100 patient years 8.70, recommendation of alternatives to anticoagulation should be considered.
5: High risk group, risk of major bleeding 9.1%, bleeds per 100 patient years 12.50, recommendation of alternatives to anticoagulation should be considered.
>5: High risk group, risk of major bleeding >10%, bleeds per 100 patient years is too high to determine risk, recommendation of alternatives to anticoagulation should be considered.
Risk of major bleeding is from Lip 2011. Bleeds per 100 patient-years is from Pisters 2010.
Clinical Application of the HAS‑BLED Calculator
In practice, the HAS‑BLED calculator is used before initiating or renewing anticoagulant therapy in patients with atrial fibrillation. It helps determine how aggressively to manage modifiable risks and guides frequency of monitoring. For example, in patients with high scores, clinicians may increase INR checks for warfarin users or reconsider the concurrent use of NSAIDs or antiplatelet agents. Importantly, the HAS‑BLED score is designed to complement—not replace—stroke risk assessments such as CHA₂DS₂‑VASc. A high HAS‑BLED score does not warrant withholding anticoagulation but should prompt measures to minimize preventable risk. In patients with modifiable factors, such as uncontrolled hypertension or excess alcohol use, interventions aimed at lowering the HAS‑BLED score may improve safety without compromising stroke prevention.
Learn more on the BackTable VI Podcast
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References
[1] Pisters, R., Lane, D. A., Nieuwlaat, R., de Vos, C. B., Crijns, H. J. G. M., & Lip, G. Y. H. (2010). A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: The Euro Heart Survey. Chest, 138(5), 1093–1100. https://doi.org/10.1378/chest.10-0134
[2] Lip, G. Y. H., Frison, L., Halperin, J. L., & Lane, D. A. (2011). Comparative validation of a novel risk score for predicting bleeding risk in anticoagulated patients with atrial fibrillation: The HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly) score. Journal of the American College of Cardiology, 57(2), 173–180. https://doi.org/10.1016/j.jacc.2010.09.024
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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