HAS-BLED Bleeding Risk Score
Calculates bleeding risk in patients with atrial fibrillation on anticoagulation to help guide therapy decisions alongside stroke risk assessment.
Risk Factors (HAS-BLED)
Uncontrolled systolic blood pressure >160 mmHg
Chronic dialysis, renal transplant, or serum creatinine ≥2.26 mg/dL (200 μmol/L)
Chronic hepatic disease (cirrhosis) or biochemical evidence of significant hepatic derangement
Previous history of stroke
Previous major bleeding, anemia, or bleeding diathesis
Unstable/high INRs or time in therapeutic range (TTR) <60%
Age greater than 65 years
Concomitant antiplatelet agents, NSAIDs
Alcohol abuse (≥8 drinks/week)
HAS-BLED Acronym
HAS-BLED Score
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About This Calculator
The HAS-BLED Score estimates the 1-year risk of major bleeding in patients with atrial fibrillation who are taking anticoagulants. It was developed from the Euro Heart Survey on Atrial Fibrillation and validated in multiple cohorts.
The acronym stands for: • H - Hypertension (uncontrolled, >160 mmHg systolic) • A - Abnormal renal/liver function • S - Stroke history • B - Bleeding history or predisposition • L - Labile INRs (if on warfarin) • E - Elderly (age >65) • D - Drugs or alcohol
Important: A high HAS-BLED score is NOT a contraindication to anticoagulation. Rather, it identifies patients who need closer monitoring and attention to modifiable risk factors (blood pressure control, avoiding NSAIDs/aspirin, alcohol moderation, better INR control).
The score should be used in conjunction with CHA₂DS₂-VASc to make informed decisions about anticoagulation therapy.
Formula
HAS-BLED = H + A(renal) + A(liver) + S + B + L + E + D(drugs) + D(alcohol)Each letter represents a risk factor worth 1 point: • Hypertension (uncontrolled, SBP >160): 1 point • Abnormal renal function: 1 point • Abnormal liver function: 1 point • Stroke history: 1 point • Bleeding history/predisposition: 1 point • Labile INRs (TTR <60%): 1 point • Elderly (>65 years): 1 point • Drugs (antiplatelets, NSAIDs): 1 point • Alcohol (≥8 drinks/week): 1 point Maximum score: 9 points
Clinical Considerations
- •A high HAS-BLED score is NOT a contraindication to anticoagulation
- •Use alongside CHA₂DS₂-VASc for complete risk assessment
- •Focus on modifiable risk factors (BP, INR control, drugs, alcohol)
- •DOACs may be preferred over warfarin in patients with labile INRs
- •Clinical judgment should guide final therapy decisions
Limitations
- •Originally validated for warfarin - DOACs have different bleeding profiles
- •Does not capture all bleeding risk factors
- •May underestimate risk in patients on dual antiplatelet therapy
- •TTR criterion less relevant for DOAC users
- •Does not account for frailty or fall risk
Interpretation Guide
| Range | Classification | Recommendation |
|---|---|---|
| <-1 | Low Risk | Low bleeding risk. Anticoagulation generally safe with standard monitoring. Address any modifiable risk factors. |
| 1-3 | Moderate Risk | Moderate bleeding risk. Anticoagulation appropriate for most patients with AF and stroke risk. Focus on modifiable risk factors and consider closer monitoring. |
| 3-10 | High Risk | High bleeding risk. Does NOT contraindicate anticoagulation but warrants careful consideration. Aggressively address modifiable factors. Consider DOAC over warfarin. More frequent monitoring advised. |
Frequently Asked Questions
What is the HAS-BLED score?
HAS-BLED is a scoring system that estimates the 1-year risk of major bleeding in patients with atrial fibrillation who are on anticoagulation. It helps clinicians balance the benefits of stroke prevention against bleeding risks.
Does a high HAS-BLED score mean I should not take blood thinners?
No. A high HAS-BLED score does NOT contraindicate anticoagulation. Most patients with high stroke risk (CHA₂DS₂-VASc ≥2) still benefit from anticoagulation. The score identifies patients needing closer monitoring and attention to modifiable risk factors.
What are modifiable HAS-BLED risk factors?
Modifiable factors include: uncontrolled hypertension (can be treated), labile INRs (switch to DOAC or improve warfarin management), concomitant drugs (avoid unnecessary NSAIDs/aspirin), and alcohol use (counseling for reduction).
How do I use HAS-BLED with CHA₂DS₂-VASc?
Calculate both scores. CHA₂DS₂-VASc determines stroke risk and need for anticoagulation. HAS-BLED helps identify patients who need closer monitoring or modification of risk factors. In most cases, if stroke risk is high, anticoagulation is still indicated even with high bleeding risk.
Is HAS-BLED still valid for DOACs?
HAS-BLED was developed in the warfarin era but remains useful for DOACs. Some criteria (like labile INRs) are less relevant, but the score still identifies patients at higher bleeding risk. DOACs generally have lower major bleeding rates than warfarin.
References
1. Pisters R, Lane DA, Nieuwlaat R, et al.. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation. Chest. 2010. doi: 10.1378/chest.10-0134
View Source →2. Hindricks G, Potpara T, Dagres N, et al.. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation. European Heart Journal. 2021. doi: 10.1093/eurheartj/ehaa612
View Source →3. January CT, Wann LS, Calkins H, et al.. 2019 AHA/ACC/HRS Focused Update of the 2014 Guideline for Management of Atrial Fibrillation. Circulation. 2019. doi: 10.1161/CIR.0000000000000665
View Source →Last updated: 2025-01-15
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