Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Clinical Trial
. 2018 Sep 18;7(18):e009766.
doi: 10.1161/JAHA.118.009766.

Predicting Bleeding Events in Anticoagulated Patients With Atrial Fibrillation: A Comparison Between the HAS-BLED and GARFIELD-AF Bleeding Scores

Marco Proietti  1   2 , José Miguel Rivera-Caravaca  3 , María Asunción Esteve-Pastor  3 , Giulio Francesco Romiti  4 , Francísco Marin  3 , Gregory Y H Lip  1   5   6
Affiliations
Clinical Trial

Predicting Bleeding Events in Anticoagulated Patients With Atrial Fibrillation: A Comparison Between the HAS-BLED and GARFIELD-AF Bleeding Scores

Marco Proietti et al. J Am Heart Assoc. .

Abstract

Background Patients with atrial fibrillation (AF) treated with oral anticoagulants may be exposed to an increased risk of bleeding events. The HAS-BLED (Hypertension, Abnormal renal and liver function, Stroke, Bleeding, Labile INRs, Elderly, Drugs or alcohol) score is a simple, well-established, clinical bleeding-risk prediction score. Recently, a new algorithm-based score was proposed, the GARFIELD-AF (Global Anticoagulant in the Field-AF) bleeding score. We compared HAS-BLED and GARFIELD-AF scores in predicting adjudicated bleeding events in a clinical trial cohort of patients with AF taking anticoagulants, in the first external comparative validation of both scores. Methods and Results We analyzed patients from the SPORTIF (Stroke Prevention Using an Oral Thrombin Inhibitor in Patients With AF) III and V trials. All patients assigned to the warfarin arm with information to calculate the scores were considered. Outcomes were major, major/clinically relevant nonmajor, and any bleeding. A total of 3550 warfarin-treated patients were available for analysis. Of these patients, 2519 (71.0%) had a HAS-BLED score ≥3, whereas based on GARFIELD-AF median value, 2056 (57.9%) were categorized as "high score." Both HAS-BLED and GARFIELD-AF C-indexes showed modest predictive value (C-index [95% confidence interval] for major bleeding, 0.58 [0.56-0.60] and 0.56 [0.54-0.57], respectively); however, GARFIELD-AF was not predictive of any bleeding. The GARFIELD-AF bleeding score had a significantly lower sensitivity and a negative reclassification for any bleeding compared with HAS-BLED, assessed by integrated discrimination improvement and net reclassification improvement (both P<0.001). HAS-BLED showed a 5% net benefit for any bleeding occurrence. Conclusions The algorithm-based GARFIELD-AF bleeding score did not show any significant improvement in major and major/clinically relevant nonmajor prediction compared with the simple HAS-BLED score. For clinical usefulness in prediction of any bleeding, the HAS-BLED score showed a significant net benefit compared with the GARFIELD-AF.

Keywords: atrial fibrillation; bleeding risk; clinical risk scores.

PubMed Disclaimer

Figures

Figure 1
Figure 1
Kaplan‐Meier curves for major and major/clinically relevant nonmajor (CRNM) bleeding for GARFIELD‐AF (Global Anticoagulant in the Field–Atrial Fibrillation) bleeding and HAS‐BLED (Hypertension, Abnormal renal and liver function, Stroke, Bleeding, Labile INRs, Elderly, Drugs or alcohol) scores.
Figure 2
Figure 2
Kaplan‐Meier curves for any bleeding for GARFIELD‐AF (Global Anticoagulant in the Field–Atrial Fibrillation) bleeding and HAS‐BLED (Hypertension, Abnormal renal and liver function, Stroke, Bleeding, Labile INRs, Elderly, Drugs or alcohol) scores.
Figure 3
Figure 3
Decision curve analysis according to GARFIELD‐AF (Global Anticoagulant in the Field–Atrial Fibrillation) bleeding and HAS‐BLED (Hypertension, Abnormal renal and liver function, Stroke, Bleeding, Labile INRs, Elderly, Drugs or alcohol) scores. CRNM indicates clinically relevant nonmajor.
See this image and copyright information in PMC

Comment in

References

    1. Lip GYH, Freedman B, de Caterina R, Potpara TS. Stroke prevention in atrial fibrillation: past, present and future comparing the guidelines and practical decision‐making. Thromb Haemost. 2017;117:1230–1239. - PubMed
    1. Lamberts M, Staerk L, Olesen JB, Fosbøl EL, Hansen ML, Harboe L, Lefevre C, Evans D, Gislason GH. Major bleeding complications and persistence with oral anticoagulation in non‐valvular atrial fibrillation: contemporary findings in real‐life Danish patients. J Am Heart Assoc. 2017;6:e004517 DOI: 10.1161/JAHA.116.004517. - DOI - PMC - PubMed
    1. Lip GYH, Andreotti F, Fauchier L, Huber K, Hylek E, Knight E, Lane D, Levi M, Marin F, Palareti G, Kirchhof P. Bleeding risk assessment and management in atrial fibrillation patients: executive summary of a position document from the European Heart Rhythm Association [EHRA], endorsed by the European Society of Cardiology [ESC] working group on thrombosis. Thromb Haemost. 2011;106:997–1011. - PubMed
    1. Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener H‐C, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P, Agewall S, Camm J, Baron Esquivias G, Budts W, Carerj S, Casselman F, Coca A, De Caterina R, Deftereos S, Dobrev D, Ferro JM, Filippatos G, Fitzsimons D, Gorenek B, Guenoun M, Hohnloser SH, Kolh P, Lip GYH, Manolis A, McMurray J, Ponikowski P, Rosenhek R, Ruschitzka F, Savelieva I, Sharma S, Suwalski P, Tamargo JL, Taylor CJ, Van Gelder IC, Voors AA, Windecker S, Zamorano JL, Zeppenfeld K. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016;37:2893–2962. - PubMed
    1. Chao T‐F, Lip GYH, Lin Y‐J, Chang S‐L, Lo L‐W, Hu Y‐F, Tuan T‐C, Liao J‐N, Chung F‐P, Chen T‐J, Chen S‐A. Incident risk factors and major bleeding in patients with atrial fibrillation treated with oral anticoagulants: a comparison of baseline, follow‐up and Delta HAS‐BLED scores with an approach focused on modifiable bleeding risk factors. Thromb Haemost. 2018;118:768–777. - PubMed

Publication types

MeSH terms