The HAS-BLED, ATRIA, and ORBIT Bleeding Scores in Atrial Fibrillation Patients Using Non-Vitamin K Antagonist Oral Anticoagulants

Published:December 21, 2017DOI:



      Various bleeding risk scores have been proposed to assess the risk of bleeding in patients with atrial fibrillation taking oral anticoagulants. Limited data are available with these scores, in users of non-vitamin K antagonist oral anticoagulants.


      Using the Danish registries, we evaluated and compared the risk classification properties of the Hypertension, Age, Stroke, Bleeding tendency/predisposition, Labile international normalized ratios, Elderly age/frailty, Drugs such as concomitant aspirin/nonsteroidal anti-inflammatory drugs or alcohol excess (HAS-BLED), Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA), and Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT) scores for predicting major bleeding in 57,930 atrial fibrillation patients (44.6% female; mean age 73.5 years, standard deviation 11.4 years; mean CHA2DS2-VASc score 3.2, standard deviation 1.8).


      At 1-year follow-up, C-statistics for ATRIA, HAS-BLED, and ORBIT were approximately 0.59, with only minor differences between scores. Both ATRIA and ORBIT categorized more patients as “low risk” (both >83%, when compared with HAS-BLED, only 53%), and qualitatively, the receiver operating characteristic curves revealed higher sensitivity (62.8%) for HAS-BLED compared with ATRIA (29.7%) and ORBIT (37.1%). The clinical usefulness of scores was evaluated using decision curve analyses at a 1-year perspective. If the intervention threshold is low (<1.7%), the benefit is toward monitoring all patients. If preference is for a major bleeding risk threshold between 1.7% and 2.0%, most benefit was obtained by using HAS-BLED. The ORBIT and ATRIA scores provided better benefit for thresholds between 2.0% and 6.0%.


      This analysis of contemporary bleeding risk score stratification in a “real-world” non-vitamin K antagonist oral anticoagulant users population with atrial fibrillation showed modest predictive values using C-statistics. The scores represent different risk thresholds, with HAS-BLED classifying least patients at low risk and achieving the highest benefit if applying a major bleeding intervention threshold of approximately 2%, whereas benefit from using either ATRIA score or ORBIT score was only evident using higher intervention thresholds.


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        • Lip G.Y.H.
        • Lane D.A.
        Stroke prevention in atrial fibrillation.
        JAMA. 2015; 313: 1950
        • Lip G.Y.H.
        • Andreotti F.
        • Fauchier L.
        • et al.
        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
        • Pisters R.
        • Lane D.A.
        • Nieuwlaat R.
        • de Vos C.B.
        • Crijns H.J.G.M.
        • Lip G.Y.H.
        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. 2010; 138: 1093-1100
        • National-Institute-for-Health-and-Care-Excellence
        Atrial fibrillation: the management of atrial fibrillation.
        (Clinical guideline 180); Available at:
        Date: 2014
        Date accessed: November 17, 2017
        • Fang M.C.
        • Go A.S.
        • Chang Y.
        • et al.
        A new risk scheme to predict warfarin-associated hemorrhage: the ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) Study.
        J Am Coll Cardiol. 2011; 58: 395-401
        • O'Brien E.C.
        • Simon D.N.
        • Thomas L.E.
        • et al.
        The ORBIT bleeding score: a simple bedside score to assess bleeding risk in atrial fibrillation.
        Eur Heart J. 2015; 36: 3258-3264
        • Kildemoes H.W.
        • Sørensen H.T.
        • Hallas J.
        The Danish National Prescription Registry.
        Scand J Public Health. 2011; 39: 38-41
        • Lynge E.
        • Sandegaard J.L.
        • Rebolj M.
        The Danish National Patient Register.
        Scand J Public Health. 2011; 39: 30-33
        • Pedersen C.B.
        The Danish Civil Registration System.
        Scand J Public Health. 2011; 39: 22-25
        • Blanche P.
        • Dartigues J.-F.
        • Jacqmin-Gadda H.
        Estimating and comparing time-dependent areas under receiver operating characteristic curves for censored event times with competing risks.
        Stat Med. 2013; 32: 5381-5397
        • Peirce C.S.
        The numerical measure of the success predictions.
        Science. 1884; 4: 453-454
        • Vickers A.J.
        • Elkin E.B.
        Decision curve analysis: a novel method for evaluating prediction models.
        Med Decis Making. 2006; 26: 565-574
        • Lip G.Y.H.
        • Lane D.A.
        Bleeding risk assessment in atrial fibrillation: observations on the use and misuse of bleeding risk scores.
        J Thromb Haemost. 2016; 14: 1711-1714
        • Wan Y.
        • Heneghan C.
        • Perera R.
        • et al.
        Anticoagulation control and prediction of adverse events in patients with atrial fibrillation: a systematic review.
        Circ Cardiovasc Qual Outcomes. 2008; 1: 84-91
        • Olesen J.B.
        • Lip G.Y.H.
        • Lindhardsen J.
        • et al.
        Risks of thromboembolism and bleeding with thromboprophylaxis in patients with atrial fibrillation: a net clinical benefit analysis using a “real world” nationwide cohort study.
        Thromb Haemost. 2011; 106: 739-749
        • Apostolakis S.
        • Lane D.A.
        • Guo Y.
        • Buller H.
        • Lip G.Y.H.
        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; 60: 861-867
        • Apostolakis S.
        • Lane D.A.
        • Guo Y.
        • Buller H.
        • Lip G.Y.H.
        Performance of the HEMORR 2 HAGES, ATRIA, and HAS-BLED bleeding risk-prediction scores in nonwarfarin anticoagulated atrial fibrillation patients.
        J Am Coll Cardiol. 2013; 61: 386-387
        • Lip G.Y.H.
        • Banerjee A.
        • Lagrenade I.
        • Lane D.A.
        • Taillandier S.
        • Fauchier L.
        Assessing the risk of bleeding in patients with atrial fibrillation: the Loire Valley Atrial Fibrillation project.
        Circ Arrhythm Electrophysiol. 2012; 5: 941-948
        • Proietti M.
        • Senoo K.
        • Lane D.A.
        • Lip G.Y.H.
        Major bleeding in patients with non-valvular atrial fibrillation: impact of time in therapeutic range on contemporary bleeding risk scores.
        Sci Rep. 2016; 6: 24376
        • Senoo K.
        • Proietti M.
        • Lane D.A.
        • Lip G.Y.H.
        Evaluation of the HAS-BLED, ATRIA, and ORBIT bleeding risk scores in patients with atrial fibrillation taking warfarin.
        Am J Med. 2016; 129: 600-607
        • Eckman M.H.
        • Singer D.E.
        • Rosand J.
        • Greenberg S.M.
        Moving the tipping point: the decision to anticoagulate patients with atrial fibrillation.
        Circ Cardiovasc Qual Outcomes. 2011; 4: 14-21
        • Kirchhof P.
        • Benussi S.
        • Kotecha D.
        • et al.
        2016 ESC Guidelines for the management of atrial fibrillation.
        Europace. 2016; 18: 1609-1678
        • Hijazi Z.
        • Oldgren J.
        • Lindback J.
        • et al.
        The novel biomarker-based ABC (age, biomarkers, clinical history)-bleeding risk score for patients with atrial fibrillation: a derivation and validation study.
        Lancet. 2016; 387: 2302-2311
        • Hijazi Z.
        • Wallentin L.
        • Siegbahn A.
        • et al.
        N-terminal Pro–B-Type natriuretic peptide for risk assessment in patients with atrial fibrillation.
        J Am Coll Cardiol. 2013; 61: 2274-2284
        • Hijazi Z.
        • Oldgren J.
        • Andersson U.
        • et al.
        Cardiac biomarkers are associated with an increased risk of stroke and death in patients with atrial fibrillation: a Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) substudy.
        Circulation. 2012; 125: 1605-1616
        • Esteve-Pastor M.A.
        • Rivera-Caravaca J.M.
        • Roldan V.
        • et al.
        Long-term bleeding risk prediction in “real world” patients with atrial fibrillation: comparison of the HAS-BLED and ABC-Bleeding risk scores.
        Thromb Haemost. 2017; 117: 1848-1858
        • Krarup L.-H.
        • Boysen G.
        • Janjua H.
        • Prescott E.
        • Truelsen T.
        Validity of stroke diagnoses in a National Register of Patients.
        Neuroepidemiology. 2007; 28: 150-154
        • Wang K.-L.
        • Lip G.Y.H.
        • Lin S.-J.
        • Chiang C.-E.
        Non–Vitamin K Antagonist oral anticoagulants for stroke prevention in Asian patients with nonvalvular atrial fibrillation.
        Stroke. 2015; 46: 2555-2561
        • Chiang C.-E.
        • Wang K.-L.
        • Lip G.Y.H.
        Stroke prevention in atrial fibrillation: an Asian perspective.
        Thromb Haemost. 2014; 111: 789-797