Overview Evidence Contributors

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.

Scoring

The 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.

Criteria	Points
Hepatic or Renal Disease	1
Ethanol (Alcohol) Abuse	1
Malignancy history	1
Age (>75)	1
Reduced Platelet Count or Function	1
Rebleeding Risk	2
Hypertension (Uncontrolled)	1
Anemia	1
Genetic Factors	1
Excessive Fall Risk	1
Stroke History	1

Results

Major Bleed Event Risk Classification	Points	Recommendation
Low-risk	0	Risk 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 warfarin
Low-risk	1	Risk 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 warfarin
Intermediate-risk	2	Consider alternatives to anticoagulation unless strong indications for warfarin therapies exist. 5.3% risk of bleeding per 100 patient-years of warfarin
Intermediate-risk	3	Consider alternatives to anticoagulation unless strong indications for warfarin therapies exist. 8.4% risk of bleeding per 100 patient-years of warfarin
High-risk	4	Alternative options should often be considered when anticoagulation is indicated. 10.4% risk of bleeding per 100 patient-years of warfarin
High-risk	5-12	Alternative options should often be considered when anticoagulation is indicated. 12.3% risk of bleeding per 100 patient-years of warfarin

Literature

Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillation (NRAF). Am Heart J. 2006 Mar;151(3):713-9. — Gage BF, Yan Y, Milligan PE, Waterman AD, Culverhouse R, Rich MW, Radford MJ.
Performance of the HEMORR(2)HAGES, ATRIA, and HAS-BLED bleeding risk-prediction scores in patients with atrial fibrillation undergoing anticoagulation: the AMADEUS (evaluating the use of SR34006 compared to warfarin or acenocoumarol in patients with atrial fibrillation) study. J Am Coll Cardiol. 2012 Aug 28;60(9):861-7. — Apostolakis S, Lane DA, Guo Y, Buller H, Lip GY.
Performance of the HAS-BLED high bleeding-risk category, compared to ATRIA and HEMORR2HAGES in patients with atrial fibrillation: a systematic review and meta-analysis. J Interv Card Electrophysiol. 2014 Sep;40(3):277-84. — Caldeira D, Costa J, Fernandes RM, Pinto FJ, Ferreira JJ.

Jennifer Glen , DNP, FNP-BC — EVAL Health, Chief Medical Officer

HEMORR2HAGES Score For Major Bleeding

Reference

Summary

Literature