Diagnostic Accuracy of the HAS-BLED Bleeding Score in VKA- or DOAC-Treated Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis

Gao, Xinxing; Cai, Xingming; Yang, Yunyao; Zhou, Yue; Zhu, Wenzhen

doi:10.3389/fcvm.2021.757087

Cited by 56 publications

(42 citation statements)

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“…9 10 11 12 45 46 Other bleeding risk scores do not offer advantages over the HAS-BLED score. 47 48 49 In a randomized controlled trial of AF patients, regular bleeding risk evaluation was associated with a reduction in bleeding events and increased anticoagulation usage. 50 Thus, appropriate and responsible use of bleeding risk scores is suggested to identify high-risk patients and address modifiable bleeding risk factors to improve patient outcome.…”

Section: Discussionmentioning

confidence: 99%

Bleeding Risk Assessment in End-Stage Kidney Disease: Validation of Existing Risk Scores and Evaluation of a Machine Learning-Based Approach

et al. 2022

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Background Patients with end-stage kidney disease (ESKD) on hemodialysis (HD) are at increased risk for bleeding. However, despite relevant clinical implications regarding dialysis modalities or anticoagulation, no bleeding risk assessment strategy has been established in this challenging population. Methods Analyses on bleeding risk assessment models were performed in the population-based Vienna InVestigation of Atrial fibrillation and thromboemboLism in patients on hemoDialysIs (VIVALDI) study including 625 patients. In this cohort study, patients were prospectively followed for a median observation period of 3.5 years for the occurrence of major bleeding. First, performances of existing bleeding risk scores (i.e., HAS-BLED, HEMORR2HAGES, ATRIA, and four others) were evaluated in terms of discrimination and calibration. Second, four machine learning-based prediction models that included clinical, dialysis-specific, and laboratory parameters were developed and tested using Monte-Carlo cross-validation. Results Of 625 patients (median age: 66 years, 38% women), 89 (14.2%) developed major bleeding, with a 1-year, 2-year, and 3-year cumulative incidence of 6.1% (95%CI 4.2-8.0), 10.3% (95%CI 8.0-12.8), and 13.5% (95%CI 10.8-16.2), respectively. C-statistics of seven contemporary bleeding risk scores ranged between 0.54 and 0.59 indicating poor discriminatory performance. The HAS-BLED score showed the highest C-statistics of 0.59 (95% 0.53-0.56). Similarly, all four machine learning-based predictions models performed poorly in internal validation (C-statistics ranging from 0.49-0.55). Conclusions Existing bleeding risk scores and a machine learning approach including common clinical parameters fail to assist in bleeding risk prediction of patients on HD. Therefore, new approaches, including novel biomarkers, to improve bleeding risk prediction in patients on HD are needed.

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Section: Discussionmentioning

confidence: 99%

Bleeding Risk Assessment in End-Stage Kidney Disease: Validation of Existing Risk Scores and Evaluation of a Machine Learning-Based Approach

et al. 2022

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“…8,9 Validation of CHA 2 DS 2 -VASc and HAS-BLED score has been reported from many Caucasians and Asian populations. [10][11][12] However, many stroke-related parameters were not included in the CHA 2 DS 2 -VASc for the prediction of SSE such as left atrial size 13 and renal function. 14 Similarly, some bleeding factors are not included in the HAS-BLED score such as some biomarkers.…”

Section: Introductionmentioning

confidence: 99%

“…In their original derivation cohorts, the C‐statistics of CHA 2 DS 2 ‐VASc and HAS‐BLED score for the prediction of SSE and major bleeding were 0.606 and 0.72, respectively 8,9 . Validation of CHA 2 DS 2 ‐VASc and HAS‐BLED score has been reported from many Caucasians and Asian populations 10–12 . However, many stroke‐related parameters were not included in the CHA 2 DS 2 ‐VASc for the prediction of SSE such as left atrial size 13 and renal function 14 .…”

Section: Introductionmentioning

confidence: 99%

Improving risk prediction for death, stroke and bleeding in Asian patients with atrial fibrillation

Krittayaphong

Kanjanarutjawiwat

Wisaratapong

et al. 2022

Eur J Clin Investigation

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Background The objectives of this study were to compare the GARFIELD Refitted model and CHA2DS2‐VASc/HAS‐BLED risk scores with the new model from the COOL‐AF registry for all‐cause death, ischaemic stroke/systemic embolism (SSE) and major bleeding in Asian patients with atrial fibrillation (AF). Methods Patients with non‐valvular AF in the nationwide COOL‐AF registry were studied. Patients were enrolled from 27 hospitals in Thailand during 2014–2017. Main outcomes were all‐cause mortality, SSE and major bleeding. Predictive models of the three outcomes were developed from the variables in the multivariable Cox‐proportional Hazard model. Predictive values of the models were evaluated by C‐statistics, calibration plots and decision curve analysis (DCA). The new COOL‐AF models were compared with the GARFIELD Refitted models and CHA2DS2‐VASc model for all‐cause mortality, SSE/HAS‐BLED model for major bleeding. Results A total of 3405 patients were enrolled. The C‐statistics for the COOL‐AF models were 0.727 (0.712–0.742), 0.708 (0.693–0.724) and 0.706 (0.690–0.721) for all‐cause mortality, SSE and major bleeding, respectively. Calibration plots showed good agreement between predicted probability the observed outcomes for the COOL‐AF models with a calibration slope of 0.94–0.99. The predictive ability remains preserved after the internal validation with bootstraps and optimism (bias) correction. The COOL‐AF predictive models tended to be superior to the GARFIELD Refitted, CHA2DS2‐VASc and HAS‐BLED models. Conclusion The COOL‐AF predictive models for all‐cause mortality, SSE and major bleeding in Asian patients with AF had a good predictive ability. The COOL‐AF model for all‐cause mortality was superior to the GARFIELD Refitted and CHA2DS2‐VASc model.

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“…Unlikely the aforementioned studies in clinical trials and the real-world situation that both stating one score is significantly better than the other, a recent meta-analysis demonstrated that the HAS-BELD score is as least non-inferior to the ABC-bleeding score with a comparable c-index value (0.61 vs. 0.65, P > 0.05) ( 22 ), while further analyses investigating the discriminative ability of these two scores were limited. In addition, another network meta-analysis suggested that the HAS-BLED score has an optimal balance of sensitivity and specificity, while the ABC-bleeding score had comparatively higher sensitivity, defined as the ratio between the number of major bleeding events in high-risk stratification and the total number of bleeding events, suggesting that the ABC-bleeding score has its own strength in stratifying high-risk patients ( 23 ).…”

Section: Discussionmentioning

confidence: 97%

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

Wang

Jiang

et al. 2022

Front. Cardiovasc. Med.

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ObjectiveTo 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.MethodsData 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.ResultsThe 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.ConclusionThis 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.

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Diagnostic Accuracy of the HAS-BLED Bleeding Score in VKA- or DOAC-Treated Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis

Cited by 56 publications

References 38 publications

Bleeding Risk Assessment in End-Stage Kidney Disease: Validation of Existing Risk Scores and Evaluation of a Machine Learning-Based Approach

Bleeding Risk Assessment in End-Stage Kidney Disease: Validation of Existing Risk Scores and Evaluation of a Machine Learning-Based Approach

Improving risk prediction for death, stroke and bleeding in Asian patients with atrial fibrillation

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

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