Clinical predictors of warfarin-associated bleeding: A case-control study.

Despite the advent of directly acting oral anticoagulants, warfarin is still widely used in resource-poor settings. Bleeding as a result of warfarin overdosage is common and risk factors seem to vary between patient populations. Predictors of bleeding in patients using warfarin were studied using a case-control design. We calculated the Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol (HAS-BLED) score (a bleeding risk prediction tool). Cases chosen were adults prescribed warfarin presenting with bleeding and controls were likewise taking warfarin but had no bleeding in the previous six months. The most common indication for warfarin use was venous thromboembolism. Recent decrease in food intake was strongly associated with bleeding. Older age, higher warfarin doses, recent illness in the past fortnight and prior bleeding were also independent predictors. A higher HAS-BLED score was not predictive independently. Closer monitoring of international normalised ratio is therefore advisable during acute illnesses and in those with decreased food intake.

Validation of the RIETE, Kuijer, and HAS-BLED Models to Assess 3-Month Bleeding Risk in Anticoagulated Patients Diagnosed with Venous Thromboembolic Disease.

OBJECTIVE: To evaluate the discriminative ability and calibration of the RIETE, Kuijer, and HAS-BLED models for predicting 3-month bleeding risk in patients anticoagulated for venous thromboembolism (VTE). METHODS: External validation study of a prediction model based on a retrospective cohort of patients with VTE seen at the Hospital Universitario San Ignacio, Bogotá (Colombia) between July 2021 and June 2023. The calibration of the scales was evaluated using the Hosmer-Lemeshow test and the ratio of observed to expected events (ROE) within each risk category. Discriminatory ability was assessed using the area under the curve (AUC) of a ROC curve. RESULTS: We analyzed 470 patients (median age 65 years, female sex 59.3%) with a diagnosis of deep vein thrombosis in most cases (57.4%), 5.7% bleeding events were observed. Regarding calibration, adequate calibration cannot be ruled out given the limited number of events. The discriminatory ability was limited with an area under the curve (AUC) of 0.48 (CI 0.37-0.59) for Kuijer Score, 0.58 (CI 0.47-0.70) for HAS-BLED and 0.64 (CI 0.51-0.76) for RIETE. CONCLUSION: The Kuijer, HAS-BLED, and RIETE models in patients with VTE generally do not adequately estimate the risk of bleeding at three months, with a low ability to discriminate high-risk patients. Cautious interpretation is recommended until further evidence is available.

Use of Neutrophil-to-Lymphocyte Ratio to Predict In-Hospital Mortality in Patients Admitted with Acute Decompensation of Atrial Fibrillation.

Background/Objectives: The prevalence of atrial fibrillation (AF) has been on the rise over the last 20 years. It is considered to be the most common cardiac arrhythmia and is associated with significant morbidity and mortality. The need for in-hospital management of patients having AF is increasing. Acute decompensation of cardiac rhythm is an indication for hospital admission. In the existing literature, several studies on different pathologies have observed that the risk of death was greater for patients with an increased neutrophil-to-lymphocyte ratio (NLR) and suggested that the NLR can be a useful biomarker to predict in-hospital mortality. This study aims to evaluate the link between the neutrophil-to-lymphocyte ratio at admission and death among the patients admitted to the medical ward for the acute manifestation of AF, and to gain a better understanding of how we can predict in-hospital all-cause death based on the NLR for these patients. Methods: A single-center retrospective study in an academic medical clinic was conducted. We analyzed if the NLR at in-hospital admission can be related to in-hospital mortality among the patients admitted for AF at the Medical Ward of Municipal Emergency University Hospital Timisoara between 2015 and 2016. After identifying a total of 1111 patients, we divided them into two groups: in-hospital death patients and surviving patients. We analyzed the NLR in both groups to determine if it is related to in-hospital mortality or not. One patient was excluded because of missing data. Results: Our analysis showed that patients who died during in-hospital admission had a significantly higher NLR compared to those who survived (p < 0.0001, 95% CI (1.54 to 3.48)). The NLR was found to be an independent predictor of in-hospital death among patients with AF, even for the patients with no raised level of blood leukocytes (p < 0.0001, 95% CI (0.6174 to 3.0440)). Additionally, there was a significant correlation between the NLR and the risk of in-hospital death for patients admitted with decompensated AF (p < 0.0001), with an area under the ROC curve of 0.745. Other factors can increase the risk of death for these patients (such as the personal history of stroke, HAS-BLED score, and age). Conclusions: The NLR is a useful biomarker to predict in-hospital mortality in patients with AF and can predict the risk of death with a sensitivity of 72.8% and a specificity of 70.4%. Further studies are needed to determine the clinical utility of the NLR in risk stratification and management of patients with AF.

Assessing adherence to treatment guidelines and complications among atrial fibrillation patients in the United Arab Emirates.

Background: Atrial fibrillation (AF), a potential trigger for stroke development, is considered a modifiable condition that can halt complications, decrease mortality, and prevent morbidity. The CHA2DS2-VASc and HAS-BLED scores are categorized as risk assessment tools used to estimate the risk of thrombosis development and assess major bleeding among atrial fibrillation patients. Objectives: Our study aims to assess the adherence to post-discharge treatment recommendations according to CHA2DS2-VASc score risk group and evaluate the impact of CHA2DS2-VASc score and HAS-BLED score risk categories on death, length of hospital stay, complications, and hospital readmission among United Arab Emirates (UAE) patients. Methods: This was a multicenter retrospective study conducted from November 2022 to April 2023 in the United Arab Emirates. Medical charts for AF patients were assessed for possible enrolment in the study. Results: A total number of 400 patients were included with a mean age of 55 (±14.5) years. The majority were females (67.8%), and most had high CHA2DS2-VASc and HAS-BLED scores (60% and 57.3%, respectively). Our study showed that adherence to treatment recommendations upon discharge was 71.8%. The bivariate analysis showed that patients with a high CHA2DS2-VASc score had a significantly higher risk of death (p-value of 0.001), hospital readmission (p-value of 0.007), and complications (p-value of 0.044) vs. the low and moderate risk group with a p-value of <0.05. Furthermore, our findings showed that the risk of death (0.001), complications (0.057), and mean hospital stay (0.003) were significantly higher in the high HAS-BLED risk score compared to both the low- and moderate-risk categories. Hospital stay was significantly higher in CHA2DS2-VASc and HAS-BLED high-risk score categories compared to the low-risk score category with a p-value of <0.001. Conclusion: Our study concluded that the adherence to treatment guidelines in atrial fibrillation patients was high and showed that patients received the most effective and patient-centered treatment. In addition, our study concluded that the risk of complications and mortality was higher in high-risk category patients.

Dynamic assessment of CHA2DS2-VASc and HAS-BLED scores for predicting ischemic stroke and major bleeding in atrial fibrillation patients.

INTRODUCTION AND OBJECTIVES: Stroke and bleeding risks in atrial fibrillation (AF) are often assessed at baseline to predict outcomes years later. We investigated whether dynamic changes in CHA2DS2-VASc and HAS-BLED scores over time modify risk prediction. METHODS: We included patients with AF who were stable while taking vitamin K antagonists. During a 6-year follow-up, all ischemic strokes/transient ischemic attacks (TIAs) and major bleeding events were recorded. CHA2DS2-VASc and HAS-BLED were recalculated every 2-years and tested for clinical outcomes at 2-year periods. RESULTS: We included 1361 patients (mean CHA2DS2-VASc and HAS-BLED 4.0±1.7 and 2.9±1.2). During the follow-up, 156 (11.5%) patients had an ischemic stroke/TIA and 269 (19.8%) had a major bleeding event. Compared with the baseline CHA2DS2-VASc, the CHA2DS2-VASc recalculated at 2 years had higher predictive ability for ischemic stroke/TIA during the period from 2 to 4 years. Integrated discrimination improvement (IDI) and net reclassification improvement (NRI) showed improvements in sensitivity and better reclassification. The CHA2DS2-VASc recalculated at 4 years had better predictive performance than the baseline CHA2DS2-VASc during the period from 4 to 6 years, with an improvement in IDI and an enhancement of the reclassification. The recalculated HAS-BLED at 2-years had higher predictive ability than the baseline score for major bleeding during the period from 2 to 4 years, with significant improvements in sensitivity and reclassification. A slight enhancement in sensitivity was observed with the HAS-BLED score recalculated at 4 years compared with the baseline score. CONCLUSIONS: In AF patients, stroke and bleeding risks are dynamic and change over time. The CHA2DS2-VASc and HAS-BLED scores should be regularly reassessed, particularly for accurate stroke risk prediction.

Comparison of bleeding risk scores and evaluation of major bleeding predictive factors in patients with major bleeding due to vitamin K antagonist use.

Background: Major bleeding in the treatment of atrial fibrillation is closely associated with an increased risk of death and major adverse outcomes in both the short and long term, but all bleeding events are associated with a reduced quality of life. Bleeding events are also known to reduce medication adherence. In this sense, bleeding risk scores are important tools to help predict major bleeding. However, it is not clear which scoring system is superior. Aim: In this study, our aim was to compare bleeding risk scores and to examine the factors associated with bleeding in patients with major bleeding while using vitamin K antagonists. Methods: In this retrospective and single-center study, scoring, laboratory and demographic data were analyzed with SPSS 20.0 statistical program. Results: The mean age of a total of 1434 patients included in our study was 68.2 ± 11.3 years, range was 39-93 years and 769 (53.6%) of these patients were male. Of 588 patients with major bleeding, 93 (15.8%) had intracranial hemorrhage. Logistic regression analysis comparing the scoring systems among themselves revealed that the GARFIELD-AF scoring system had a predictive effect on major bleeding independent of the effect of other scoring systems (OR: 1.532, 95% CI 1.348-1.741, p < 0.001). The area under the curve (AUC) for GARFIELD-AF was 0.690 (0.662-0.718) as a result of the ROC analysis considering the best cut-off point of 3.2% calculated for 2 years. AUC 0.659 (0.630-0.687) for HAS-BLED, AUC 0.636 (0.606-0.665) for ORBIT and AUC 0.611 (0.5810.642) for ATRIA. When we compare the patient group with the control group, it can be said that intracranial hemorrhage occurred independently of INR and TTR values, unlike in the major bleeding group (p:0.129, p:0.545). Conclusion: In patients using vitamin K antagonists for atrial fibrillation, the GARFIELD-AF risk score was found to be superior to important bleeding risk scores such as HAS-BLED, ORBIT and ATRIA in terms of predicting major bleeding. It is an important result that intracranial hemorrhages, which have a special place among major hemorrhages, were independent of INR and TTR levels. It is noteworthy that 8.2% of patients with major bleeding had a history of minor bleeding in the last year.

Application of validated bleeding risk scores for atrial fibrillation in obscure gastrointestinal bleeding patients increases videocapsule endoscopy's diagnostic yield: a retrospective monocentric study.

BACKGROUND: Videocapsule endoscopy (VCE) is considered the gold standard for overt and obscure gastrointestinal bleeding (OGIB), after negative upper and lower endoscopy. Nonetheless, VCE's diagnostic yield is suboptimal, and it represents a costly, time-consuming, and often not easily available technique. In order to evaluate bleeding risk in patients with atrial fibrillation, several scoring systems have been proposed, but their utilization outside the original clinical setting has rarely been explored. The aim of the study is to evaluate potential role of bleeding risk scoring systems in predicting the occurrence of positive findings at VCE examination, and therefore in increasing VCE diagnostic yield. METHODS: Data from consecutive patients undergoing VCE between April 2015 and June 2020 were retrospectively retrieved, and clinical and demographic characteristics were collected. HAS-BLED, ATRIA, and ORBIT scores were calculated, and patients were considered at low or high risk of bleeding accordingly. Discriminative ability of the scores for positive VCE findings has been evaluated by area under receiver operator characteristic curve (AUC) calculation. Diagnostic yield of scores in high- and low-risk patients was calculated. RESULTS: A total of 413 patients underwent VCE examination, among which 368 (89%) for OGIB. Positive findings were observed in 246 patients (67%), with angiodysplasias being the most frequent lesion (92%). The three scores displayed similar consistent discriminative ability for positive VCE findings (mean AUC = 0.69), and identified high-risk group of patients in which VCE has a higher diagnostic yield. CONCLUSIONS: In the present retrospective study, bleeding scores accurately discriminated patients with higher probability of positive findings at VCE examination. Bleeding scores utilization may help in the management of patients with OGIB, with a potential consistent resource optimization and cost-saving.

Clinical Outcome of Deep Vein Thrombosis Is Related to Thrombophilic Risk Factors.

Deep vein thrombosis (DVT) and the associated possible complication of pulmonary artery embolism (LAE) represent a recognized reason for significant perioperative morbidity and mortality. There is a risk of pulmonary artery embolism through embolization. The aim of the study was to investigate the influence of various risk factors on the clinical outcome of the therapy, particularly regarding whether maintenance therapy offers a benefit in terms of the frequency of bleeding and thrombotic events. 80 patients were included, some of them retrospectively from July 2018. The observational period was set to 12 months after the DVT event. In the present sample with n = 80, with 57.5% men and 42.5% women (after 12 months of observation: n = 78), a success rate of the therapies administered of 89.7% was recorded. Only 8.9% showed partial recanalization. 3.8% of the patients had a relapse (also beyond the localization of the leg and pelvic veins) and 8.8% had a residual thrombus during the first 12 months of observation. In this study, BARC (Bleeding Academic Research Consortium) and HAS-BLED (Hypertension, Abnormal renal and liver function, Stroke, Bleeding, Labile INR, Elderly, Drugs or alcohol) scores for identifying the risk of bleeding and Wells scores for assessing the risk of having a thrombosis were used. The Villalta score tested in this study showed significant correlations with residual thrombus (P < .001), recurrence within 12 months (P < .001), and the risk of bleeding (P < .001) and is capable to provide an assessment of the variables mentioned not only at the possible end of therapy but also at the start of anticoagulant therapy.

Stroke in hemodialysis patients and its association with CHA2DS2-VASC and HAS-BLED scores: a retrospective study.

Background: In the general population, the CHA2DS2-VASC and the HAS-BLED scores are helpful to predict cerebrovascular events and hemorrhage in patients with atrial fibrillation (AF). However, their predictive value remains controversial in the dialysis population. This study aims to explore the association between these scores and cerebral cardiovascular events in hemodialysis (HD) patients. Methods: This is a retrospective study including all HD patients treated between January 2010 and December 2019 in two Lebanese dialysis facilities. Exclusion criteria are patients younger than 18 years old and patients with a dialysis vintage less than 6 months. Results: A total of 256 patients were included (66.8% men; mean age 69.3 ± 13.9 years). The CHA2DS2-VASc score was significantly higher in patients with stroke (P = .043). Interestingly, this difference was significant in patients without AF (P = .017). Using receiver operating curve analysis, CHA2DS2-VASc score had an area under the curve (AUC) of 0.628 [95% confidence interval (CI): 0.539-0.718) and the best cut-off value for this score was 4. The HAS-BLED score was also significantly higher in patients with a hemorrhagic event (P < .001). AUC for HAS-BLED score was 0.756 (95% CI: 0.686-0.825) and the best cut-off value was also 4. Conclusions: In HD patients, CHA2DS2-VASc score can be associated with stroke and HAS-BLED score can be associated with hemorrhagic events even in patients without AF. Patients with a CHA2DS2-VASc score ≥4 are at the highest risk for stroke and adverse cardiovascular outcomes, and those with a HAS-BLED score ≥4 are at the highest risk for bleeding.

Supra-therapeutic Anticoagulation with Warfarin: A Cross-sectional Study.

AIMS: To identify the extent and associated factors for patients with prolonged prothrombin time, international normalized ratio (PT-INR), and the dosage modifications were carried out with warfarin. BACKGROUND: Studies evaluating patients on warfarin with supratherapeutic anticoagulation are limited. It is vital to understand the management strategies for patients receiving warfarin who are bleeding and those with only supratherapeutic PT-INR. OBJECTIVE: To evaluate the factors associated with supratherapeutic anticoagulation without bleeding with warfarin. METHODS: A cross-sectional study was carried out on patients receiving long-term warfarin with at least one PT-INR value > 3.2. Percent time in therapeutic range (TTR) was calculated and National Institute for Health and Care Excellence (NICE) guidelines were adhered to defining anticoagulation control into good (> 65%) and poor (< 65%). RESULTS: One hundred and forty-four patients were recruited. Nearly half of the study population had PT-INR values between 3.2 and 3.9. On average, individuals had at least 4 times PT-INR values in the supratherapeutic range. Elderly patients were observed with a significant trend of supratherapeutic INR. Duration of therapy was significantly correlated with the risk of PT-INR > 4. Lower TTR was observed in patients with frequent PT-INR > 4 and those patients had significantly poor anticoagulation control. Duration of warfarin therapy and HAS-BLED scores were observed to be significant predictors of supratherapeutic INR. Large variations were observed in the modifications of warfarin dose carried out at various supratherapeutic INR values and consequently PTINR values. CONCLUSION: We observed that the majority of patients with supratherapeutic INR had their INR values between 3.2 and 3.9. Elderly patients, with higher HAS-BLED scores and prolonged duration of warfarin therapy, were observed with an increased risk of supratherapeutic anticoagulation. Careful dosage modifications are needed particularly in high-risk categories as mentioned above.

Performance of the HAS-BLED, ORBIT, and ATRIA Bleeding Risk Scores on a Cohort of 399 344 Hospitalized Patients With Atrial Fibrillation and Cancer: Data From the French National Hospital Discharge Database.

Background The association between cancer types and specific bleeding events in patients with atrial fibrillation has been scarcely investigated. Also, the performance of bleeding risk scores in this high-risk subgroup of patients is unclear. We investigated the rate of any bleeding, intracranial hemorrhage, major bleeding, and gastrointestinal bleeding according to cancer types in patients with atrial fibrillation. We also tested the predictive value of HAS-BLED, ATRIA, and ORBIT bleeding risk scores. Methods and Results Observational retrospective cohort study including hospitalized patients with atrial fibrillation and cancer from the French National Hospital Discharge Database (Programme de Medicalisation des Systemes d'Information) from January 2010 to December 2019. Major bleeding was defined according to Bleeding Academic Research Consortium definitions. Patients with HAS-BLED ≥3, ATRIA ≥5, or ORBIT ≥4 were classified as at high bleeding risk. Receiver operating characteristic analysis for each score against any bleeding, major bleeding, gastrointestinal bleeding, and intracranial hemorrhage was performed. Areas under the curve (AUCs) were then compared. We included 399 344 patients. Mean age was 77.9±10.2 years, and 63.2% were men. The highest intracranial hemorrhage rates were found in leukemia (1.89%/year), myeloma (1.52%/year), lymphoma and liver (1.45%/year), and pancreas cancer (1.41%/year). Receiver operating characteristic analysis showed that ORBIT score predicted best for any bleeding. In addition, ORBIT score ≥4 had the highest predictivity for major bleeding (AUC, 0.805), followed by HAS-BLED ≥3 and ATRIA ≥5 (AUCs, 0.716 and 0.700, respectively). HAS-BLED and ORBIT performed best for intracranial hemorrhage (AUCs, 0.744 and 0.742 for continuous scores, respectively), better than ATRIA (AUC, 0.635). For gastrointestinal bleeding, ORBIT ≥4 had the highest predictivity (AUC, 0.756), followed by the HAS-BLED ≥3 (AUC, 0.702) and ATRIA ≥5 (AUC, 0.662). Conclusions Some cancer types carry a greater bleeding risk in patients with atrial fibrillation. The identification and management of modifiable bleeding risk factors is crucial in these patients, as well as to flag up high bleeding risk patients for early review and follow-up.

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.

Performance of the ABC-bleeding risk score for assessing major bleeding risk in Chinese patients with atrial fibrillation on oral anticoagulation therapy: A real-world study.

Objective: To evaluate performance of the ABC (Age, Biomarkers, Clinical history)-bleeding risk score in estimating major bleeding risk in Chinese patients with atrial fibrillation (AF) on oral anticoagulation (OAC) therapy in real-world practice. Methods: Data were collected from the Chinese Atrial Fibrillation Registry study (CAFR). Patients were stratified into low-, medium-, and high-risk groups based on ABC-bleeding risk score with 1-year major bleeding risk (<1%, 1-2%, and > 2%) and modified HAS-BLED score (≤1, 2, and > 2 points). Cox proportional-hazards (Cox-PH) models were used to determine the association of major bleeding incidence with bleeding scores. Harrell's C-index of the two scores were compared. Net reclassification improvement (NRI) and integrated discrimination improvement (IDI) at 1 year were employed to evaluate the reclassification capacity. The calibration curve was plotted to compare the predicted major bleeding risk using ABC-bleeding risk score with the observed annualized event rate. The decision analysis curves (DCA) were performed to show the clinical utilization of two scores in identifying major bleeding events. Results: The study included 2,892 AF patients on OAC therapy. After the follow-up of 3.0 years, 48 patients had major bleeding events; the incidence of a bleeding event in the low-, medium-, and high-risk groups according to ABC-bleeding risk score was 0.31% (reference group, HR = 1.00),0.51% (HR = 1.83, 95%CI: 0.91-3.69, P = 0.09), and 1.49% (HR = 4.92, 95%CI: 2.34-10.30, P < 0.001), respectively. Major bleeding incidence had an independent association with growth differentiation factor 15 (GDF-15) level (HR = 2.16, 95%CI: 1.27-3.68, P = 0.005) after adjusting components of the HAS-BLED score and cTnT-hs level. The ABC-bleeding score showed a Harrell's C-index of 0.67 (95%CI: 0.60-0.75) in estimating major bleeding risk, which was non-significant compared to the modified HAS-BLED score (0.67 vs. 0.63; P = 0.38). NRI and IDI also revealed comparable reclassification capacity of ABC-bleeding risk score compared with HAS-BLED score (14.6%, 95%CI: -10.2%, 39.4%, P = 0.25; 0.2%, 95%CI -0.1 to 0.9%, P = 0.64). Cross-tabulation of the two scores showed that the ABC-bleeding score outperformed the HAS-BLED score in identifying patients with a high risk of major bleeding. The calibration curve showed that the ABC-bleeding risk score overestimated the observed major bleeding risk. DCA did not show any difference in net benefit when using either of the scores. Conclusion: This study verified the value of the ABC-bleeding risk score in assessing major bleeding risk in Chinese patients with AF on OAC therapy in real-world practice. Despite the overestimation of major bleeding risk, ABC-bleeding score performed better in stratifying patients with a high risk than the modified HAS-BLED score. Combining the two scores could be a clinically practical strategy for precisely stratifying AF patients, especially those at a high risk of major bleeding, and further supporting the optimization of OAC treatment.

Empiric Anticoagulation Therapy in Hospitalized COVID-19 Patients: An Evaluation of Bleeding Risk Scores Performances in Predicting Bleeding Events.

Currently, there is no standardized consensus on anticoagulation (AC) among patients with coronavirus disease (COVID-19), which has an overwhelming bleeding risk. We aimed to compare the patterns of AC in COVID-19 patients and compare two validated risk scores in predicting bleeding events. A retrospective review of medical records was conducted for COVID-19 patients who received empiric anticoagulation therapy. The primary outcomes included bleeding events, survival, and mechanical ventilation needs. We applied the HAS-BLED and ORBIT bleeding risk scores to assess the predictive accuracy, using c-statistics and the receiver operating curve (ROC) method. Of the included patients (n = 921), with a mean age of 58.1 ± 13.2, 51.6% received therapeutic AC and 48.4% received a prophylactic AC dose. Significantly higher values of d-dimer and C-reactive protein (CRP) among the therapeutic AC users (p < 0.001) were noted with a significantly prolonged duration of hospital stay and mechanical ventilation (p < 0.001 and p = 0.011, respectively). The mean value of the HAS-BLED and ORBIT scores were 2.53 ± 0.93 and 2.26 ± 1.29, respectively. The difference between the two tested scores for major bleeding and clinically relevant non-major bleeding was significant (p = 0.026 and 0.036, respectively) with modest bleeding predictive performances. The therapeutic AC was associated with an increased risk of bleeding. HAS-BLED showed greater accuracy than ORBIT in bleeding risk predictability.

Comparing Atrial-Fibrillation Validated Rapid Scoring Systems in the Long-Term Mortality Prediction in Patients Referred for Elective Coronary Angiography: A Subanalysis of the Bialystok Coronary Project.

Rapid scoring systems validated in patients with atrial fibrillation (AF) may be useful beyond their original purpose. Our aim was to assess the utility of CHA2DS2-VASc, HAS−BLED, and 2MACE scores in predicting long-term mortality in the population of the Bialystok Coronary Project, including AF patients. The initial study population consisted of 7409 consecutive patients admitted for elective coronary angiography between 2007 and 2016. The study endpoint was all-cause mortality, which occurred in 1244 (16.8%) patients during the follow-up, ranging from 1283 to 3059 days (median 2029 days). We noticed substantially increased all-cause mortality in patients with higher values of all compared scores. The accuracy of the scores in predicting all-cause mortality was also assessed using the receiver operator characteristic (ROC) curves. The greatest predictive value for mortality was recorded for the CHA2DS2-VASc score in the overall study population (area under curve [AUC] = 0.665; 95% confidence interval [95%CI] 0.645−0.681). We observed that the 2MACE score (AUC = 0.656; 95%CI 0.619−0.681), but not the HAS−BLED score, had similar predictive value to the CHA2DS2-VASc score for all-cause mortality in the overall study population. In AF patients, all scores did not differ in all-cause mortality prediction. Additionally, we found that study participants with CHA2DS2-VASc score ≥3 vs. <3 had a 3-fold increased risk of long-term all-cause mortality (odds ratio 3.05; 95%CI 2.6−3.6). Our study indicates that clinical scores initially validated in AF patients may be useful for predicting mortality in a broader population (e.g., in patients referred for elective coronary angiography). According to our findings, all compared scores have a moderate predictive value. However, in our study, the CHA2DS2-VASc and 2MACE scores outperformed the HAS−BLED score in terms of the long-term all-cause mortality prediction.

Revised HAS-BLED score for bleeding prediction in atrial fibrillation patients with oral anticoagulants.

Background: There were several limitations to the original HAS-BLED (oHAS-BLED) score in patients with atrial fibrillation (AF). This trial studied the revised HAS-BLED (rHAS-BLED) score for predicting bleeding events in anticoagulated AF patients. Methods: This study retrospectively recruited anticoagulated AF patients in the Central Chest Institute of Thailand between 2014 and 2021. The rHAS-BLED score was oHAS-BLED using the estimated glomerular filtration rate of <60 ml/min/1.73 m2 for abnormal renal function, SAMe-TT2R2 score of ≥3 for labile INR, and adding clinically relevant nonmajor bleeding (CRNMB) into bleeding history. The outcome was major bleeding (MB) and/or CRNMB at 1-year follow-up visit. The outcome between both groups was compared by using the chi-square test or Fisher's exact test. Receiver-operating characteristics curve was used to analyze the discrimination performances of both scores and the results were illustrated by using c-statistics. Results: A total of 256 anticoagulated AF patients were enrolled. The average age was 73.6 ± 10.1 years. The average oHAS-BLED and rHAS-BLED scores were 1.7 ± 0.9 and 2.6 ± 1.2, respectively. Twenty patients in rHAS-BLED ≥3 (15.9%) and 9 patients in rHAS-BLED <3 (6.9%) experienced MB and/or CRNMB. The rHAS-BLED score of ≥3 increased the bleeding risk with statistical significance (OR 2.54, 95% CI 1.11-5.81, p = .04). The discriminative performance of the rHAS-BLED score was illustrated with c-statistics of 0.61 (95% CI 0.50-0.71). Conclusions: The rHAS-BLED score could predict bleeding events in anticoagulated AF patients. However, a larger study is needed to confirm these results in the future.

Predictive Value of HAS-BLED Score Regarding Bleeding Events and Graft Survival following Renal Transplantation.

Objective: Due to the high prevalence and incidence of cardio- and cerebrovascular diseases among dialysis-dependent patients with end-stage renal disease (ERSD) scheduled for kidney transplantation (KT), the use of antiplatelet therapy (APT) and/or anticoagulant drugs in this patient population is common. However, these patients share a high risk of complications, either due to thromboembolic or bleeding events, which makes adequate peri- and post-transplant anticoagulation management challenging. Predictive clinical models, such as the HAS-BLED score developed for predicting major bleeding events in patients under anticoagulation therapy, could be helpful tools for the optimization of antithrombotic management and could reduce peri- and postoperative morbidity and mortality. Methods: Data from 204 patients undergoing kidney transplantation (KT) between 2011 and 2018 at the University Hospital Leipzig were retrospectively analyzed. Patients were stratified and categorized postoperatively into the prophylaxis group (group A)­patients without pretransplant anticoagulation/antiplatelet therapy and receiving postoperative heparin in prophylactic doses­and into the (sub)therapeutic group (group B)­patients with postoperative continued use of pretransplant antithrombotic medication used (sub)therapeutically. The primary outcome was the incidence of postoperative bleeding events, which was evaluated for a possible association with the use of antithrombotic therapy. Secondary analyses were conducted for the associations of other potential risk factors, specifically the HAS-BLED score, with allograft outcome. Univariate and multivariate logistic regression as well as a Cox proportional hazard model were used to identify risk factors for long-term allograft function, outcome and survival. The calibration and prognostic accuracy of the risk models were evaluated using the Hosmer−Lemshow test (HLT) and the area under the receiver operating characteristic curve (AUC) model. Results: In total, 94 of 204 (47%) patients received (sub)therapeutic antithrombotic therapy after transplantation and 108 (53%) patients received prophylactic antithrombotic therapy. A total of 61 (29%) patients showed signs of postoperative bleeding. The incidence (p < 0.01) and timepoint of bleeding (p < 0.01) varied significantly between the different antithrombotic treatment groups. After applying multivariate analyses, pre-existing cardiovascular disease (CVD) (OR 2.89 (95% CI: 1.02−8.21); p = 0.04), procedure-specific complications (blood loss (OR 1.03 (95% CI: 1.0−1.05); p = 0.014), Clavien−Dindo classification > grade II (OR 1.03 (95% CI: 1.0−1.05); p = 0.018)), HAS-BLED score (OR 1.49 (95% CI: 1.08−2.07); p = 0.018), vit K antagonists (VKA) (OR 5.89 (95% CI: 1.10−31.28); p = 0.037), the combination of APT and therapeutic heparin (OR 5.44 (95% CI: 1.33−22.31); p = 0.018) as well as postoperative therapeutic heparin (OR 3.37 (95% CI: 1.37−8.26); p < 0.01) were independently associated with an increased risk for bleeding. The intraoperative use of heparin, prior antiplatelet therapy and APT in combination with prophylactic heparin was not associated with increased bleeding risk. Higher recipient body mass index (BMI) (OR 0.32 per 10 kg/m2 increase in BMI (95% CI: 0.12−0.91); p = 0.023) as well as living donor KT (OR 0.43 (95% CI: 0.18−0.94); p = 0.036) were associated with a decreased risk for bleeding. Regarding bleeding events and graft failure, the HAS-BLED risk model demonstrated good calibration (bleeding and graft failure: HLT: chi-square: 4.572, p = 0.802, versus chi-square: 6.52, p = 0.18, respectively) and moderate predictive performance (bleeding AUC: 0.72 (0.63−0.79); graft failure: AUC: 0.7 (0.6−0.78)). Conclusions: In our current study, we could demonstrate the HAS-BLED risk score as a helpful tool with acceptable predictive accuracy regarding bleeding events and graft failure following KT. The intensified monitoring and precise stratification/assessment of bleeding risk factors may be helpful in identifying patients at higher risks of bleeding, improved individualized anticoagulation decisions and choices of antithrombotic therapy in order to optimize outcome after kidney transplantation.

Can CHA2DS2-VASc and HAS-BLED Foresee the Presence of Cerebral Microbleeds, Lacunar and Non-Lacunar Infarcts in Elderly Patients With Atrial Fibrillation? Data From Strat-AF Study.

Anticoagulants reduce embolic risk in atrial fibrillation (AF), despite increasing hemorrhagic risk. In this context, validity of congestive heart failure, hypertension, age ≥ 75 years, diabetes, stroke, vascular disease, age 65-74 years and sex category (CHA2DS2-VASc) and hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol concomitantly (HAS-BLED) scales, used to respectively evaluate thrombotic and hemorrhagic risks, is incomplete. In patients with AF, brain MRI has led to the increased detection of "asymptomatic" brain changes, particularly those related to small vessel disease, which also represent the pathologic substrate of intracranial hemorrhage, and silent brain infarcts, which are considered risk factors for ischemic stroke. Routine brain MRI in asymptomatic patients with AF is not yet recommended. Our aim was to test predictive ability of risk stratification scales on the presence of cerebral microbleeds, lacunar, and non-lacunar infarcts in 170 elderly patients with AF on oral anticoagulants. Ad hoc developed R algorithms were used to evaluate CHA2DS2-VASc and HAS-BLED sensitivity and specificity on the prediction of cerebrovascular lesions: (1) Maintaining original items' weights; (2) augmenting weights' range; (3) adding cognitive, motor, and depressive scores. Accuracy was poor for each outcome considering both scales either in phase 1 or phase 2. Accuracy was never improved by the addition of cognitive scores. The addition of motor and depressive scores to CHA2DS2-VASc improved accuracy for non-lacunar infarcts (sensitivity = 0.70, specificity = 0.85), and sensitivity for lacunar-infarcts (sensitivity = 0.74, specificity = 0.61). Our results are a very first step toward the attempt to identify those elderly patients with AF who would benefit most from brain MRI in risk stratification.

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 <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 < 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.

Risk factors associated with post-extraction bleeding in patients on warfarin or direct-acting oral anticoagulants: a retrospective cohort study.

PURPOSE: The purpose of this study was to investigate the risk factors associated with post-extraction persistent bleeding in patients on warfarin or direct-acting oral anticoagulants (DOACs) and the ability of risk scores to predict post-extraction bleeding. METHODS: Three hundred ninety-one patients taking warfarin or DOACs underwent tooth extractions. Various risk factors for post-extraction bleeding, including number of tooth extraction, with antiplatelet therapy, and risk scores, were investigated by univariate and multivariate analyses. A post-extraction bleeding was classified into grades 1-3. RESULTS: The incidence of post-extraction bleeding was 26.8% (77 out of 287 patients; grade 1: 63, grade 2:14) in patients taking warfarin, and 26.0% (27 out of 104 patients; grade 1: 20, grade 2:7) in patients taking warfarin DOACs. Multivariate analyses showed that multiple teeth extractions and HAS-BLED scores (above 3 points) in patients taking warfarin, and only multiple teeth extractions in patients taking DOAC, were significantly associated with post-extraction bleeding, respectively. CONCLUSION: Most of the post-extraction bleedings were grade 1, which can be stopped by eligibly pressing gauze by surgeons. If patients taking anticoagulants are scheduled to undergo multiple teeth extractions or their HAS-BLED score are above 3 points (if warfarin), we recommend informing patients risk of post-extraction bleeding before operation, taking carefully hemostasis, and instructing patients to bite down accurately on the gauze for longer than usual.