Update in office management
Implications of the CHA2DS2-VASc and HAS-BLED Scores for Thromboprophylaxis in Atrial Fibrillation

https://doi.org/10.1016/j.amjmed.2010.05.007Get rights and content

Abstract

There is increasing recognition of the value of oral anticoagulation for stroke prevention in atrial fibrillation, as well as the availability of new oral anticoagulants that overcome the limitations of warfarin, implying that even more atrial fibrillation patients will be using oral anticoagulation, with the role of aspirin being less defined. Thus, we need a paradigm shift so that stroke risk assessment can be simplified in the identification of those patients who are truly at low risk (ie, CHA2DS2-VASc [Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, Stroke, Vascular disease, Age 65-74 years, Sex category] score = 0) who could be treated with no antithrombotic therapy, and all others (ie, CHA2DS2-VASc score ≥1), would be considered for oral anticoagulation. A simple bleeding risk assessment can clearly help guide office management here. The new HAS-BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile International Normalized Ratio, Elderly, Drugs/alcohol concomitantly) bleeding risk schema has been proposed as a simple, easy calculation to assess bleeding risk in atrial fibrillation patients, whereby a score of ≥3 indicates “high risk” and some caution and regular review of the patient is needed, following the initiation of antithrombotic therapy, whether with oral anticoagulation or antiplatelet therapy.

Section snippets

How Can We Assess Bleeding Risk?

Many risk factors for stroke are also risk factors for bleeding.7 Furthermore, previously published schemes for bleeding risk stratification (Table 2) by Shireman et al,8 Gage et al9 (with the acronym HEMORR2HAGES), Beyth et al,10 and Kuijer et al11 have been difficult to apply in routine clinical practice, with some being based on complex scoring systems,9, 11 and only one scheme having been formally derived (and then validated) in an atrial fibrillation cohort.9 A lack of consensus and

How Would a Simple, Easy Score in Assessing Bleeding Risk Help Office Management of Atrial Fibrillation Patients?

Recent data have shown that even in “moderate risk” patients (ie, CHADS2 score = 1), oral anticoagulation is superior to aspirin for stroke and mortality prevention,13 and among “low risk” atrial fibrillation patients (ie, CHADS2 score = 0), aspirin may be no better than control for the reduction of thromboembolism, with a risk of increased bleeding.14 When aspirin alone was compared with placebo or no treatment in 7 trials, a meta-analysis showed that aspirin was associated with a non-significant

How Would the HAS-BLED Score Help Office Management with Future Developments in Thromboprophylaxis for Atrial Fibrillation?

The landscape has recently changed with new oral anticoagulants that avoid some of the limitations and disadvantages of warfarin. In the RE-LY (Randomized Evaluation of Long-term anticoagulant therapY) trial, for example, dabigatran 100 mg twice daily was noninferior to warfarin for stroke prevention, with 20% less major bleeding events; while dabigatran 150 mg twice daily was superior in efficacy for stroke prevention compared with warfarin, with a similar rate of major bleeds.18 The

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    The relative risk of thromboembolic events is high; however, the absolute risk remains very low, at a rate of 1–2 events per 100 patient-years. For example, if anticoagulation is held for 5 days preoperatively and 7 days postoperatively, the 12-day risk of a cerebral ischemic event is 1.0%, assuming a daily rate of 0.033% according to the CHA2DS2-VASc and a 2.5 times increase in hypercoagulability associated with perioperative holding of anticoagulation.4,14 This risk is balanced against the potentially fatal risk of an IPH.

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Funding: None.

Conflict of Interest: Dr. Lip has received funding for research, educational symposia, consultancy, and lecturing from different manufacturers of drugs used for the treatment of atrial fibrillation and thrombosis.

Authorship: The author had a full role in writing the manuscript.

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