Comparing the ORBIT and HAS-BLED bleeding risk scores in anticoagulated atrial fibrillation patients: a systematic review and meta-analysis

Meta-analysis on performance of ABC and GARFIELD-AF compared to CHA2DS2-VASc and HAS-BLED in anticoagulated atrial fibrillation patients

BACKGROUND

When high thromboembolic and bleeding risks coexist, the former tends to influence physicians' decision making for anti-coagulation therapy. However, the ideal is to weigh the risk of major bleeding and stroke together to ensure effective anti-coagulation treatment, which is a limitation of traditional guideline recommended CHA2DS2-VASc and HAS-BLED. This meta-analysis assesses the performance of the two new scores - ABC and GARFIELD-AF compared to CHA2DS2-VASc and HAS-BLED for major bleeding and stroke outcomes in patients with atrial fibrillation (AF) on anticoagulation therapy.

METHODS

MEDLINE and Cochrane central were searched from 2010 to February 2023 that compared GARFIELD-AF and/or ABC with CHA2DS2-VASc and/or HAS-BLED scores using C-statistics to assess their discriminative ability.

RESULTS

12 studies were included in this meta-analysis. When assessing stroke risk prediction, GARFIELD-AF stroke (C-Statistic: 0.71; 95 % CI: 0.70-0.72; I2 = 0 %, p < 0.05) was found to be significantly better than ABC-stroke (C-Statistic: 0.67; 95 % CI: 0.65-0.68; I2 = 0 %, p < 0.05), and CHA2DS2-VASc (C-Statistic: 0.64; 95 % CI: 0.60-0.67; I2 = 92 %, p < 0.05). Additionally, when assessing bleeding risk prediction, ABC-bleeding (C-Statistic: 0.66; 95 % CI: 0.61-0.70; I2 = 84 %, p < 0.05), GARFIELD-AF (C-Statistic: 0.64; 95 % CI: 0.60-0.68; I2 = 95 %, p < 0.05), and HAS-BLED (C-Statistic: 0.64; 95 % CI: 0.62-0.66; I2 = 85 %, p < 0.05) all showed equivalent performances.

CONCLUSION

The GARFIELD-AF stroke score showed superior performance to the well-established CHA2DS2-VASc score as well as the ABC-stroke score. Therefore, new guidelines should favor GARFIELD-AF use in clinical practice.

Risk scores for major bleeding from direct oral anticoagulants: comparing predictive performance in patients with atrial fibrillation

Background

Despite direct oral anticoagulants (DOACs) being safer than warfarin for stroke prevention in atrial fibrillation (AF), major bleeding concerns persist. Most bleeding risk scores predate DOAC approval.

Objectives

This study aimed to compare the Age, history of Bleeding, and non-bleeding related Hospitalisation [ABH] score's performance-derived for DOAC-treated patients-with those of 5 other scores (Anticoagulation and Risk Factors in Atrial Fibrillation [ATRIA], Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly [>65 years], Drugs/alcohol concomitantly [HAS-BLED], Hepatic, Hepatic or Renal Disease, Ethanol Abuse, Malignancy, Older Age, Reduced Platelet Count or Function, Re-Bleeding, Hypertension, Anemia, Genetic Factors, Excessive Fall Risk and Stroke [HEMORR2HAGES], Outcomes Registry for Better Informed Treatment of Atrial Fibrillation [ORBIT-AF], and Congestive heart failure, Hypertension, Age ≥75 [doubled], Diabetes, Stroke [doubled]-Vascular disease, Age 65-74, Sex category [CHA2DS2-VASc]) in predicting DOAC-related major bleeding in patients with AF.

Methods

In this retrospective study of 2364 patients with nonvalvular AF on rivaroxaban or apixaban (median age, 68.3 years; 32.1% women), International Society on Thrombosis and Haemostasis-defined major bleeding (incidence, 4.1%; n = 97) was analyzed. C-statistics from time-dependent receiver operating characteristic (ROC) curves for continuous risk scores were the primary comparison metric, but other metrics, such as decision curves, were also compared.

Results

At 100 days, C-statistics were highest for ORBIT-AF and ATRIA (0.62 and 0.61, respectively, with other scores having an area under the ROC curve of <0.60); some significant differences favored ORBIT-AF. At 1100 days, C-statistics remained highest for ORBIT-AF and ATRIA (0.62 and 0.61, respectively, with other scores having an area under the ROC curve of <0.60 again), and ORBIT-AF had significantly higher C-statistics than those for all other risk scores (P < .05), except for ATRIA. At 2100 days, all C-statistics were <0.60 with no significant differences. Decision curves showed the greatest net benefit for ORBIT-AF and ATRIA at 100 days and for ATRIA at 1100 days, with no discernible net benefit for any of the scores at 2100 days.

Conclusion

ORBIT-AF and ATRIA provided the best bleeding risk prediction within the first 1100 days. None of the 6 bleeding risk scores provided predictive benefit over 2100 days of DOAC treatment.

Less major bleeding and higher hemoglobin after left atrial appendage closure in high-risk patients: Data from a long-term, longitudinal, two-center observational study

BACKGROUND

Left atrial appendage closure (LAAC) is a mechanical alternative for stroke prevention in patients at risk who cannot tolerate oral anticoagulation (OAC).

HYPOTHESIS

Our hypothesis was that the reduction of anticoagulation following LAAC results in a decrease of bleeding events and a rise in serum hemoglobin in a high-risk collective of patients with atrial fibrillation (AF).

METHODS

Bleeding events, use of erythrocyte concentrates, anticoagulation, embolic events, and serum hemoglobin levels before and following LAAC were compared over more than 4 years.

RESULTS

Seventy-five patients (CHA₂DS₂-VASc score 4.4 ± 1.7, HAS-BLED score 4.6 ± 1.1) were analyzed. Before LAAC (observation period 1.8 ± 1.8 years), 67 patients experienced 1.8 ± 1.4 bleeding events (0.9 ± 1.3 major) per year resulting in 0.7 ± 1.3 transfusions per year. After LAAC (2.6 ± 2.0 years), 26 patients (p < .0001 vs. before) had 0.6 ± 2.1 bleeding events (p < .0001), 0.2 ± 0.6 major bleedings (p < .0001) and received 0.6 ± 1.9 transfusions per year (p = .671). Fourteen patients had stroke before and 3 after LAAC (p = .008). Serum hemoglobin increased from initially 9.9 ± 3.0 to 11.9 ± 2.3 g/dL until the end of follow-up (p = .0005). Adverse embolic events did not differ before and after LAAC in our collective.

CONCLUSION

In this clinical relevant cohort of AF patients with high risk for stroke and intolerance to OAC, we show that LAAC was able to reduce the rate of stroke and bleeding events, which translated into a rising serum hemoglobin concentration.

Anticoagulant use in older persons at risk for falls: therapeutic dilemmas-a clinical review

PURPOSE

The aim of this clinical narrative review was to summarise the existing knowledge on the use of anticoagulants and potential adverse events in older people at risk of falls with a history of atrial fibrillation or venous thromboembolism. The review also offers practical steps prescribers can take when (de-)prescribing anticoagulants to maximise safety.

METHODS

Literature searches were conducted using PubMed, Embase and Scopus. Additional articles were identified by searching reference lists.

RESULTS

Anticoagulants are often underused in older people due to concerns about the risk of falls and intracranial haemorrhage. However, evidence suggests that the absolute risk is low and outweighed by the reduction in stroke risk. DOACs are now recommended first line for most patients due to their favourable safety profile. Off-label dose reduction of DOACs is not recommended due to reduced efficacy with limited reduction in bleeding risk. Medication review and falls prevention strategies should be implemented before prescribing anticoagulation. Deprescribing should be considered in severe frailty, limited life expectancy and increased bleeding risk (e.g., cerebral microbleeds).

CONCLUSION

When considering whether to (de-)prescribe anticoagulants, it is important to consider the risks associated with stopping therapy in addition to potential adverse events. Shared decision-making with the patient and their carers is crucial as patient and prescriber views often differ.

Predicting performance of the HAS-BLED and ORBIT bleeding risk scores in patients with atrial fibrillation treated with Rivaroxaban: Observations from the prospective EMIR Registry

BACKGROUND

Assessing bleeding risk during the decision-making process of starting oral anticoagulation (OAC) therapy in atrial fibrillation (AF) patients is essential. Several bleeding risk scores have been proposed for vitamin K antagonist users but, few studies have focused on validation of these bleeding risk scores in patients taking direct oral anticoagulants (DOACs). The aim was to compare the predictive ability of HAS-BLED and ORBIT bleeding risk scores in AF patients taking rivaroxaban in the EMIR ('Estudio observacional para la identificación de los factores de riesgo asociados a eventos cardiovasculares mayores en pacientes con fibrilación auricular no valvular tratados con un anticoagulante oral directo [Rivaroxaban]) Study.

METHODS AND RESULTS

EMIR Study was an observational, multicenter, post-authorization, and prospective study that involved AF patients under OAC with rivaroxaban at least 6 months before enrolment. We analysed baseline clinical characteristics and adverse events after 2.5 years of follow-up and validated the predictive ability of HAS-BLED and ORBIT scores for major bleeding (MB) events.We analysed 1433 patients with mean age of 74.2 ± 9.7 (44.5% female). Mean HAS-BLED score was 1.6 ± 1.0 and ORBIT score was 1.1 ± 1.2. The ORBIT score categorised a higher proportion of patients as 'low-risk' (87.1%) compared with 53.5% using the HAS-BLED score. There were 33 MB events (1.04%/year) and 87 patients died (2.73%/year). Both HAS-BLED and ORBIT had a good predictive ability for MB{Area under the curve (AUC) 0.770, [95% confidence interval (CI) 0.693-0.847; P <0.001] and AUC 0.765 (95% CI 0.672-0.858; P <0.001), respectively}. There was a non-significant difference for discriminative ability of the two tested scores (P = 0.930) and risk reclassification in terms of net reclassification improvement (NRI) -5.7 (95% CI -42.4-31.1; P = 0.762). HAS-BLED score showed the best calibration and ORBIT score showed the largest mismatch in calibration, particularly in higher predicted risk patients.

CONCLUSION

In a prospective real-world AF population under rivaroxaban from EMIR registry, the HAS-BLED score had good predictive performance and calibration compared with ORBIT score for MB events. ORBIT score presented worse calibration than HAS-BLED in this DOAC treated population.

Comparing atrial fibrillation guidelines: Focus on stroke prevention, bleeding risk assessment and oral anticoagulant recommendations

Clinical practice in atrial fibrillation (AF) patient management is constantly evolving. In the past 3 years, various new AF guidelines or focused updates have been published, given this rapidly evolving field. In 2019, the American College of Cardiology/American Heart Association published a focused update of the 2014 guidelines. In 2020, both the European Society of Cardiology and the Canadian Cardiovascular Society released their new guidelines. Finally, the most recent guidelines were those published in 2021 by the Asian Pacific Heart Rhythm Society, which updates their 2017 version and the 2021 National Institute for Health and Care Excellence (NICE) guidelines. In the present narrative review, we compare these guidelines, emphasizing similarities and differences in the following mainstay elements of patient care: thromboembolic risk assessment, oral anticoagulants (OACs) prescription, bleeding risk evaluation, and integrated patient management. A formal evaluation of baseline thromboembolic and bleeding risks and their reassessment during follow-up is evenly recommended, although some differences in using risk stratification scores. OACs prescription is highly encouraged where appropriate, and prescription algorithms are broadly similar. The importance of an integrated and multidisciplinary approach to patient care is emerging, aiming to address several different aspects of a multifaceted disease.

Mitral Regurgitation and Body Mass Index Increase the Predictability of Perioperative Bleeding in Anticoagulated Patients With Nonvalvular Atrial Fibrillation

Background

Catheter ablation (CA) effectively restores sinus rhythm in atrial fibrillation (AF) but causes a short-term fluctuation in the coagulation state. Potential risk factors and better management during this perioperative period remain understudied.

Methods

We consecutively included 940 patients with nonvalvular AF who received CA at Fuwai Hospital, Beijing, China. Patients were divided into two groups according to their bleeding status during 3 months' anticoagulation. Any adverse events related to bleeding in the 3 months were evaluated. The HAS-BLED score and ABC-bleeding score, as well as other potential factors, were explored to predict bleeding risk.

Results

In this observational study, 8.0% and 0.9% of the whole population suffered from bleeding and thromboembolic events, respectively. After adjusting for known factors related to bleeding, mitral regurgitation (MR, p for trend &lt;0.001) and body mass index (BMI, odds ratio (OR) = 0.920, 95% CI 0.852–0.993, p = 0.033) were the most significant ones. C-indexes of the HAS-BLED score and ABC-bleeding score for bleeding were 0.558 (0.492–0.624) and 0.585 (0.515–0.655), respectively. The incorporation of MR and BMI significantly improved the predictive value based on HAS-BLED score (C-index = 0.650, 95% CI 0.585–0.715, p = 0.004) and ABC-bleeding score (C-index = 0.671, 95% CI 0.611–0.731, p &lt; 0.001). The relative risk of mild-moderate MR was 4.500 (95% CI 1.625–12.460) in patients with AF having HAS-BLED = 1 and 4.654 (95% CI 1.496–14.475) in HAS-BLED ≥ 2, while it was not observed in patients with HAS-BLED = 0 (p = 0.722).

Conclusion

More severe MR and lower BMI are associated with a higher incidence of perioperative bleeding, which helps improve the predictability of increased individual bleeding risk of a patient with nonvalvular AF who has received CA therapy and oral anticoagulants.

Is There a Role for Triple Therapy After ACS?

PURPOSE OF REVIEW

The optimal antithrombotic strategy in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) remains the subject of controversy. In this article, we review the current evidence for the use of triple therapy in acute coronary syndrome (ACS) patients.

RECENT FINDINGS

The recently published trials of AF patients undergoing PCI have shown that combination of non-vitamin K oral anticoagulants (NOACs) with an antiplatelet agent is either superior or non-inferior to vitamin K antagonist (VKA) plus dual antiplatelet therapy (DAPT) in reducing bleeding complications with no difference in regard to thromboembolic events. Currently, the use of dual therapy (preferably with a NOAC and clopidogrel) is recommended over triple therapy in these patients. The optimal duration should be guided by the assessment of an individual's risk of thrombosis and bleeding events.

Comparison of HAS-BLED and ORBIT Bleeding Risk Scores in AF Patients treated with NOACs: A Report from the ESC-EHRA EORP-AF General Long-Term Registry

INTRODUCTION

Bleeding risk assessment is recommended in guidelines for the management of atrial fibrillation (AF). HAS-BLED score was proposed prior to non-vitamin K antagonist oral anticoagulants (NOACs) and has been suggested that the ORBIT score may be superior in predicting bleeds in NOAC users. We aimed to compare the HAS-BLED and ORBIT scores in contemporary AF patients treated with NOACs.

METHODS AND RESULTS

We analyzed patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. HAS-BLED and ORBIT scores were computed based on original schemes. The primary outcome was the occurrence of Major Bleeding (MB). A total of 3018 patients (median age 70; 39.6% females) were included: median [IQR] HAS-BLED and ORBIT scores were 1 [1-2] and 1 [0-2], respectively; 356 (11.8%) patients were at high risk for MB using HAS-BLED (≥3) and 123 (4.1%) using ORBIT (≥4). Overall, 60 (2.0%) MB events were recorded, with an incidence of 1.1 per 100 patient-years.Both HAS-BLED and ORBIT were associated with outcome, modestly predicting MB (AUC 0.653, 95% CI 0.593-0.714 and AUC 0.601, 95% CI 0.526-0.677, respectively). Calibration plots showed that both scores were poorly calibrated, particularly the ORBIT score, which showed consistent poorer calibration. Time-dependent reclassification analysis showed a trend towards incorrect lower risk reclassification using ORBIT compared to HAS-BLED.

CONCLUSION

In this real-life contemporary cohort of AF patients treated with NOACs, the ORBIT score did not provide reclassification improvement, showing even poorer calibration compared to HAS-BLED. Our findings do not support the preferential use of ORBIT in NOAC-treated AF patients.

Comparative Analysis of Risk Stratification Scores in Atrial Fibrillation

BACKGROUND

Atrial Fibrillation (AF) has become a major global health concern and is associated with an increased risk of poor outcomes. Identifying risk factors in patients with AF can be challenging, given the high burden of comorbidities in these patients. Risk stratification schemes appear to facilitate accurate prediction of outcomes and assist therapeutic management decisions.

OBJECTIVE

To summarize current evidence on risk stratification scores for patients with AF.

RESULTS

Traditional risk models rely heavily on demographics and comorbidities, while newer tools have been gradually focusing on novel biomarkers and diagnostic imaging to facilitate more personalized risk assessment. Several studies have been conducted to compare existing risk schemes and identify specific patient populations in which the prognostic ability of each scheme excels. However, current guidelines do not appear to encourage the implementation of risk models in clinical practice, as they have not incorporated new ones in their recommendations for the management of patients with AF for almost a decade.

CONCLUSION

Further work is warranted to analyze new reliable risk stratification schemes and optimally implement them into routine clinical life.

Beyond the 2020 guidelines on atrial fibrillation of the European society of cardiology

The most recent atrial fibrillation (AF) guidelines delivered by European Society of Cardiology (ESC) offer an updated approach to AF management, with the perspective of improved characterization of the arrhythmia, the cardiac substrate and the patients profile in terms of associated risk factors and comorbidities. Recommendations were based on careful scrutiny and assessment of all available evidence with the final aim to offer to practitioners a lower level of uncertainty in the complex process of decision making for patients with AF. The 2020 ESC guidelines on AF propose a paradigm shift in the clinical approach to AF patients, moving from a single-domain AF classification to comprehensive characterization of AF patients. Given the complex nature of AF, an integrated holistic management of AF patients is suggested by the guidelines for improving patients outcomes through the formal introduction of the CC (Confirm AF and Characterize AF) to ABC (Atrial fibrillation Better Care) pathway. In line with this concept, these new guidelines underline the importance of a more comprehensive management of AF patients which should not be limited to simply prescribe oral anticoagulation or decide between a rhythm or rate control strategy. Indeed, each step of the ABC pathway represents one of the pivotal pillars in the management of AF and only a holistic approach has the potential to improve patients' outcomes. In this review we will discuss the background that supports some of the new recommendations of 2020 ESC guidelines, with important implications for daily management of AF patients.

Comparison of HAS-BLED with other risk models for predicting the bleeding risk in anticoagulated patients with atrial fibrillation: A PRISMA-compliant article

BACKGROUND

The HAS-BLED, HEMORR2HAGES, ATRIA, and ORBIT scores are used to predict bleeding risk in anticoagulated patients with atrial fibrillation (AF). Recently, these scores have been validated in various studies. Therefore, we aimed to compare the occurrence of major bleeding across different risk categories between HAS-BLED and any of HEMORR2HAGES, ATRIA, or ORBIT scores.

METHODS

A systemic literature search of PubMed and Embase databases was conducted to screen the relevant studies. We calculated and pooled the odds ratios (ORs) and 95% confidence intervals (CIs) for a comparative analysis of the occurrence of major bleeding.

RESULTS

Nine studies fulfilled the inclusion criteria in this meta-analysis. Compared with HEMORR2HAGES, there were 87% and 39% reduced rates of major bleeding in the HAS-BLED "low-risk" and "moderate-risk" groups, respectively. Compared with ATRIA, there was an 89% decreased rate of major bleeding in the HAS-BLED "low-risk" group. Compared with ORBIT, there were 84% and 44% reduced rates of major bleeding in the HAS-BLED "low-risk" and "moderate-risk" groups, respectively. Patients with HAS-BLED scores ≥3 showed an approximately 3-fold greater risk of major bleeding compared with patients with scores <3 (OR=3.00, CI: 1.21-7.43).

CONCLUSIONS

Compared with any of HEMORR2HAGES, ATRIA, or ORBIT scores, the HAS-BLED score distributed more major bleeding events into the "low" or "moderate" risk categories.

Accuracy of HAS-BLED and other bleeding risk assessment tools in predicting major bleeding events in atrial fibrillation: A network meta-analysis

BACKGROUND

Preventing thrombosis is an important part of atrial fibrillation (AF) treatment. However, it may increase the risk of bleeding, and bleeding risk assessment tools' predictive value remains unclear. This network meta-analysis investigated the sensitivity and specificity of HAS-BLED, and other bleeding risk assessment tools, to predict major bleeding events in AF patients.

METHODS

The PubMed, EMBASE, and Cochrane Central Register of Controlled Trials databases were searched using keywords, including "AF," "bleeding," and "HAS-BLED," for results published through 30 November 2018. The predictive sensitivity and specificity of each bleeding risk assessment tool was analyzed by network meta-analysis.

RESULTS

Our analysis included 18 studies, recruiting a total of 321 888 people. The bleeding risk assessment tools analyzed in this study included the ABC-bleeding score, ATRIA, European score, GARFIELD-AF, HAS-BLED, HEMORR2HAGES, ORBIT, Shireman, and mOBRI. A comprehensive analysis of sensitivity and specificity, based on an inconsistency model, showed that European score, ABC, and mOBRI have relatively high-sensitivity but low-specificity tools, whereas HAS-BLED and HEMORR2HAGES have balanced sensitivity and specificity. ORBIT, ATRIA, Shireman, and GARFIELD-AF had relatively high specificity but low sensitivity. A consistency model analysis showed similar results.

CONCLUSIONS

HAS-BLED is a balanced bleeding risk assessment tool in terms of sensitivity and specificity, whereas the European score, ABC, and mOBRI are high-sensitivity tools and ORBIT, ATRIA, Shireman, and GARFIELD-AF are high-specificity tools.

External Validation of the ORBIT Bleeding Score and the HAS-BLED Score in Nonvalvular Atrial Fibrillation Patients Using Direct Oral Anticoagulants (Asian Data from the DIRECT Registry)

For Asian patients with nonvalvular atrial fibrillation (NVAF) using direct oral anticoagulants (DOACs), performance of contemporary various bleeding risk scores in a real-world setting is unknown. The objective of this study was to externally validate the ORBIT bleeding score and the HAS-BLED score in a large pooled real-world Asian population with NVAF using DOACs. We conducted a single-center prospective observational registry of NVAF patients treated with DOACs: the DIRECT registry (UMIN000033283). We assessed predictive and discriminative performance of the ORBIT bleeding and the HAS-BLED scores for major bleeding in 2,216 patients with NVAF using DOACs (63.6% male, median age 73 years, median CHADS₂ score 2). The overall incidence of major bleeding was 4.2% after a median follow-up of 315 days (interquartile range: 76 to 621). The ORBIT bleeding and the HAS-BLED scores both had modest discrimination ability to identify those who had bled versus who had not (C index = 0.64 [95% confidence interval {CI} 0.59, 0.70] and 0.62 [95% CI 0.57, 0.68], respectively). Calibration plots of the ORBIT bleeding score showed similar predictive performance compared with the HAS-BLED score (slope: 0.91 [95% CI 0.40, 1.43] vs 0.72 [95% CI 0.03, 1.40], intercept: 0.24 [95% CI -2.13, 2.61] vs 0.71 [95% CI -2.35, 3.76], respectively). In conclusion, the ORBIT bleeding score and the HAS-BLED score in a real-world of NVAF population with DOACs showed a modest discriminative performance and a similar predictive performance for major bleeding.

Discriminative Ability of CHA2DS2-VASc and HAS-BLED Score in Whites and Nonwhites

The CHA₂DS₂-VASc and HAS-BLED scoring systems are used in patients with atrial fibrillation (AF) to estimate risk of stroke and bleeding, respectively. Both were developed in minimally diverse European populations and these scores have not yet been extensively studied in US whites and nonwhites. In a retrospective cohort study, we included patients with AF who received inpatient or outpatient care in a large integrated academic health system from 2011 to 2017. Cox proportional hazards were used to analyze associations between stroke and CHA₂DS₂-VASc score in AF patients not prescribed anticoagulation and between incident bleeding and HAS-BLED score in anticoagulated patients. After exclusions for previous stroke, the cohort included 21,648 patients with a mean age of 66.8 ± 15.8. Anticoagulation was prescribed in 52% of whites and 46% of nonwhites (p < 0.001) with a CHA₂DS₂-VASc score of ≥2. Mean CHA₂DS₂-VASc scores were 2.4 ± 1.6 in whites and 2.2 ± 1.6 in nonwhites and mean HAS-BLED scores was 1.5 ± 1.1 in whites and 1.3 ± 1.0 in nonwhites. After adjusting for baseline differences, the discriminative ability of CHA₂DS₂-VASc and HAS-BLED was similar in whites and nonwhites (p = 0.52, 0.33, respectively). The discriminative ability of HAS-BLED was similar in patients on vitamin K antagonists and direct oral anticoagulants. In conclusion, oral anticoagulation was prescribed less frequently in nonwhites. However, the discriminative ability of CHA₂DS₂-VASc and HAS-BLED were similar in whites and nonwhites.

Anticoagulation risk assessment for patients with non-valvular atrial fibrillation and venous thromboembolism: A clinical review

Non-valvular atrial fibrillation and venous thromboembolism anticoagulation risk assessment tools have been increasingly utilized to guide implementation and duration of anticoagulant therapy. Anticoagulation significantly reduces stroke and recurrent venous thromboembolism risk, but comes at the cost of increased risk of major and clinically relevant non-major bleeding. The decision for anticoagulation in high-risk patients is complicated by the fact that many risk factors associated with increased thromboembolic risk are simultaneously associated with increased bleeding risk. Traditional risk assessment tools rely heavily on age, sex, and presence of cardiovascular comorbidities, with newer tools additionally taking into account changes in risk factors over time and novel biomarkers to facilitate more personalized risk assessment. These tools may help counsel and inform patients about the risks and benefits of starting or continuing anticoagulant therapy and can identify patients who may benefit from more careful management. Although the ability to predict anticoagulant-associated hemorrhagic risk is modest, ischemic and bleeding risk scores have been shown to add significant value to therapeutic management decisions. Ultimately, further work is needed to optimally implement accurate and actionable risk stratification into clinical practice.