Information 1–4

  • HAS-BLED is a tool to assess bleeding risk and support clinical decision making for patients on anticoagulant therapy:
    • Hypertension
    • Abnormal renal/liver function
    • Stroke
    • Bleeding history or predisposition
    • Labile international normalized ratio (INR)
    • Elderly (>65 years)
    • Drugs (medicines) and alcohol concomitantly

1. Calculator 1–4

Table 1. HAS-BLED calculator

Risk factor

Score

Hypertension

  • Systolic blood pressure > 160 mmHg

1

Abnormal renal function

  • Dialysis, renal transplantation and/or serum creatinine ≥ 200 mmol/L

1

Abnormal liver function

  • Chronic liver disease (e.g. cirrhosis) or biochemical evidence of significant hepatic derangement (e.g. bilirubin twice upper limit of normal in association with AST / ALT / ALP 3 x upper limit normal etc.)

1

Stroke

1

Bleeding tendency or predisposition

  • History of intracranial bleeding, bleeding requiring hospitalisation, haemoglobin fall >20mg/mL, and/or transfusion

1

Labile international normalised ratio (INR)

  • Time in therapeutic range < 60%

1

Elderly

  • Age > 65 years

1

Medicines that predispose to bleeding

  • Aspirin, clopidogrel, NSAIDs

1

Alcohol use

  • Excessive alcohol ≥ 8 drinks/week

1

Scoring

  • Score ≥ 3 equates to high risk of bleeding; caution and regular review is recommended
  • A high score does not necessarily indicate avoiding anticoagulant medicines

2. Considerations 1–4

  • In patients with a high bleeding risk, all bleeding risk factors should be identified addressed and monitored throughout treatment
  • Modifiable bleeding risk factors:
    • hypertension i.e. SBP > 160 mmHg
    • labile INR or time in therapeutic range < 60% if taking warfarin
    • medicines that predispose patients to bleeding e.g. aspirin, clopidogrel, NSAIDs
    • excessive alcohol consumption i.e. ≥ 8 drinks/week
  • Potentially modifiable bleeding risk factors:
    • anaemia
    • impaired kidney function
    • impaired liver function
    • reduced platelet count or function
  • Non-modifiable bleeding risk factors:
    • age > 65 years, or ≥ 75 years
    • history of major bleeding
    • previous stroke
    • dialysis-dependent kidney disease or kidney transplant
    • cirrhotic liver disease
    • malignancy
    • genetic factors
  • Educate patients about the benefits and risks of anticoagulant medicines, so they can contribute to management decisions
  • Favour non-vitamin K oral anticoagulants (NOACs; dabigatran, rivaroxaban, apixaban) over warfarin as they are:
    • as good as or better in reducing stroke and systemic embolism
    • have a lower risk of intracranial haemorrhage as a side effect
    • easier for patients and clinicians to manage and use
  • If a patient is already on warfarin it is reasonable to change to a NOAC
  • Antiplatelet therapy is not recommended for stroke prevention regardless of stroke risk

3. References

4. Resources

  1. HAS-BLED online calculator

Last updated: September 2024

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