Numerous researchers have shown that there is a close correlation between red cell distribution width (RDW) and cardiovascular disease such as heart failure, coronary heart disease, and atrial ...fibrillation. This study was designated to investigate the correlation between RDW and the Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly, Drugs/alcohol (HAS-BLED) score.
The HAS-BLED scores of 251 hospitalized patients with non-valvular atrial fibrillation were calculated and the receiver operating characteristics were used to evaluate the predictive value of RDW on high HAS-BLED score (≥3 scores). Multiple logistic regression analysis was used to analyze the independent predictor of high HAS-BLED scores.
Correlation analysis between RDW and HAS-BLED scores showed the RDW was positively correlated with HAS-BLED score, with r=0.393 (P<0.0001). The RDW of the high HAS-BLED score group was higher than that of the no-high HAS-BLED score group. The area under the receiver operating characteristic curve of RDW was 0.796 (0.740-0.844, P<0.0001) to predict a high HAS-BLED score, and multiple logistic regression analysis showed that a high RDW value could be used as an independent predictor of high HAS-BLED.
RDW value is associated with HAS-BLED value, and can be used as the independent predictive factor of high HAS-BLED scores.
Trends in the use of antithrombotic drugs in elderly patients with atrial fibrillation (AF) are largely unknown. We estimated the prevalence of AF in an older population, and examined whether use of ...anticoagulant and antiplatelet drugs in older AF patients has changed over time.
Data from the population-based Swedish National study on Aging and Care in Kungsholmen (n=3363, age≥60years, 64.9% women) were used (2001–2004 and 2007–2010). AF cases were identified through 12-lead electrocardiogram, physician examinations, and patient register records (ICD-10 code I48). We used the CHADS2 and CHA2DS2-VASc scores to estimate stroke risk, and an incomplete HAS-BLED score to estimate bleeding risk.
At baseline (2001–2004), 328 persons (9.8%) were ascertained to have AF. The prevalence of AF increased significantly with age from 2.8% in people aged 60–66years to 21.2% in those ≥90years, and was more common in men than in women (11.2% vs. 9.0%). Among AF patients with CHADS2 score ≥2 at baseline, 25% were taking anticoagulant drugs and 54% were taking antiplatelet drugs. High bleeding risk was significantly associated with not using anticoagulant drugs in AF patients (multi-adjusted OR=2.50, p=0.015). Between 2001–2004 and 2007–2010, use of anticoagulant drugs increased significantly, especially in AF patients with CHA2DS2-VASc score ≥2 (23% vs. 33%, p=0.008) and in those with HAS-BLED score <3 (32% vs. 53%, p=0.004).
AF is common among old people. The use of anticoagulant drugs increased over time in AF patients, yet still two-thirds of those with high stroke risk remained untreated.
The HAS-BLED, HEMORR2HAGES, ATRIA, and ORBIT scores are used to predict bleeding risk in anticoagulated patients with atrial fibrillation (AF). Recently, these scores have been validated in various ...studies. Therefore, we aimed to compare the occurrence of major bleeding across different risk categories between HAS-BLED and any of HEMORR2HAGES, ATRIA, or ORBIT scores.
A systemic literature search of PubMed and Embase databases was conducted to screen the relevant studies. We calculated and pooled the odds ratios (ORs) and 95% confidence intervals (CIs) for a comparative analysis of the occurrence of major bleeding.
Nine studies fulfilled the inclusion criteria in this meta-analysis. Compared with HEMORR2HAGES, there were 87% and 39% reduced rates of major bleeding in the HAS-BLED "low-risk" and "moderate-risk" groups, respectively. Compared with ATRIA, there was an 89% decreased rate of major bleeding in the HAS-BLED "low-risk" group. Compared with ORBIT, there were 84% and 44% reduced rates of major bleeding in the HAS-BLED "low-risk" and "moderate-risk" groups, respectively. Patients with HAS-BLED scores ≥3 showed an approximately 3-fold greater risk of major bleeding compared with patients with scores <3 (OR=3.00, CI: 1.21-7.43).
Compared with any of HEMORR2HAGES, ATRIA, or ORBIT scores, the HAS-BLED score distributed more major bleeding events into the "low" or "moderate" risk categories.
CHADS2 and CHA2DS2-VASc scores are used to estimate thromboembolic risk in atrial fibrillation (AF). HAS-BLED is recommended for bleeding risk prediction. Their value in predicting the outcome of AF ...patients after percutaneous coronary intervention (PCI) is unknown. Thus, our aim was to assess whether these simple risk scores are useful in predicting outcome in these patients.
AFCAS is an observational, multicenter, prospective registry including patients (n=929) with AF referred for PCI. Primary study endpoints were 1) all cause mortality; 2) major adverse events (all-cause mortality, myocardial infarction, repeat revascularization, stent thrombosis, transient ischemic attack, stroke or other arterial thromboembolism; MACCE); and 3) bleeding at 12 months follow-up. CHADS2 and CHA2DS2-VASc scores and a modified HAS-BLED (mHAS-BLED) score (omitting labile INR and liver function) were calculated.
Patients were distributed as follows: CHADS2 low 29.5%, intermediate 55.2%, high 15.3%; CHA2DS2-VASc low 9.6%, intermediate 46.0%, high 44.5%. A high CHA2DS2-VASc score was predictive of all-cause mortality (p=0.02), whereas CHADS2 was not. High CHA2DS2-VASc score predicted MACCE (HR 2.24, 95%CI 1.21-4.17, p=0.01), as did a high CHADS2 score (HR 1.60, 95%CI 1.05-2.45, p=0.029). Their predictive performance was only modest (C indexes 0.56-0.57). CHADS2 or CHA2DS2-VASc scores were not associated with bleeding. High mHAS-BLED scores (≥3) were not associated with any of the study outcomes.
High CHA2DS2-VASc score was the best predictor of thrombotic outcomes after PCI in a high risk AF population. High mHAS-BLED score was not predictive of bleeding events. More accurate, simple risk scores are needed.
Atrial fibrillation (AF) significantly increases the risk of stroke and, therefore, stroke prevention is an essential component of the management for patients with AF. This requires formal assessment ...of the individual risk of stroke to determine if the patient is eligible for oral anticoagulation (OAC), and if so, their risk of bleeding on OAC, before a treatment decision regarding stroke prevention is made. Risk of stroke is not homogenous; it depends on the presence or absence of risk factors. A plethora of stroke and bleeding risk factors has been identified, including common and less-well established clinical risk factors, plus imaging, urine, and blood biomarkers. Consequently, there are several stroke and bleeding risk stratification scores available and this article provides an overview of them, the risk factors included and how they are scored, and provides a critical appraisal of them. The review also discusses the debate regarding whether female sex is a risk factor or a risk modifier, and highlights the dynamic nature of both stroke and bleeding risk and the need to re-assess these risks periodically to ensure treatment is optimal to reduce the risk of adverse outcomes. This review also summarizes the recommended stroke and bleeding risk stratification scores from all current major international guidelines.
Background
The bleeding risk profile of patients with atrial fibrillation (AF) may change over time, and the increment of HAS-BLED score is perceived to result in discontinuations of oral ...anticoagulants (OACs).
Objectives
To investigate the changes of HAS-BLED scores of AF patients initially with a low bleeding risk. The associations between continuation or discontinuation of OACs and clinical outcomes after patients’ bleeding risk profile worsened (ie HAS-BLED increased) were studied.
Methods
The present study used Taiwan nationwide health insurance research database. From year 2000 to 2015, a total of 24,990 AF patients aged ≥ 20 years with a CHA
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-VASc score ≥ 1 (males) or ≥ 2 (females) having an HAS-BLED score of 0–2 who were treated with OACs were identified and followed up for changes of the HAS-BLED scores. Patients who did not refill OACs within 90 days after their HAS-BLED scores increased to ≥ 3 were defined as discontinuations of OACs. The risks of clinical outcomes were compared between patients who continued or stopped OACs once their HAS-BLED scores increased to ≥ 3.
Results
Mean HAS-BLED score of study population increased from 1.54 to 3.33. At end of 1 year, 5,229 (20.9%) patients had an increment of their HAS-BLED scores to ≥ 3, mainly due to newly diagnosed hypertension, stroke, bleeding, and concomitant drug therapies. Among 4777 patients who consistently had an HAS-BLED score ≥ 3, 1,062 (22.2%) stopped their use of OACs. Patients who kept on OACs (
n
= 3715; 77.8%) even after their HAS-BLED scores increased to ≥ 3 were associated with a lower risk of ischemic stroke (aHR 0.60, 95%CI 0.53–0.69), major bleeding (aHR 0.78, 95%CI 0.67–0.91), all-cause mortality (aHR 0.88, 95%CI 0.79–0.97), and any adverse events (aHR 0.75, 95%CI 0.68–0.82) adjusted for age, sex, heart failure, and HAS-BLED score. These results were consistent among the cohorts after propensity matching.
Conclusions
For patients whose HAS-BLED scores increased to ≥ 3, the continuation of OACs was associated with better clinical outcomes. An increased HAS-BLED score in anticoagulated AF patients may not be the only reason to withhold OACs, but reminds physicians to correct modifiable bleeding risk factors and follow up patients more closely.
Graphical abstract
Associations between Continuation or Discontinuation of Oral Anticoagulants and Risks of Clinical Outcomes after HAS-BLED Scores Increased
AF
atrial fibrillation;
aHR
adjusted hazard ratio;
ICH
intra-cranial hemorrhage;
OACs
oral anticoagulants
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.
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.
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.
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.
A menudo la evaluación de los riesgos de ictus y hemorragia en la fibrilación auricular (FA) es basal para predecir los resultados años después. Sin embargo, estos riesgos no son estáticos. Se investiga si los cambios dinámicos en CHA2DS2-VASc y HAS-BLED a lo largo del tiempo modifican la predicción del riesgo.
Se incluyó a pacientes con FA estables en tratamiento con antagonistas de la vitamina K. Durante 6 años de seguimiento, se registraron todos los ictus isquémicos/accidentes isquémicos transitorios (AIT) y hemorragias mayores. El CHA2DS2-VASc y HAS-BLED se revaluaron cada 2 años y se investigaron los resultados clínicos en periodos de 2 años.
Se incluyó a 1.361 pacientes (medias de CHA2DS2-VASc y HAS-BLED, 4,0±1,7 y 2,9±1,2). Durante el seguimiento, 156 pacientes (11,5%) sufrieron un ictus isquémico/AIT y 269 (19,8%), una hemorragia mayor. En comparación con el valor basal, el CHA2DS2-VASc recalculado a los 2 años presentó mayor capacidad predictiva de ictus isquémico/AIT durante el periodo de 2-4 años. El índice de mejoría de la discriminación (IDI) y el índice de reclasificación neta (NRI) mostraron mejoras en la sensibilidad y mejor reclasificación. El CHA2DS2-VASc recalculado a los 4 años arrojó un mejor rendimiento predictivo que el basal durante el periodo de 4-6 años, con una mejora en el IDI y una mejora de la reclasificación. El HAS-BLED recalculado a los 2 años presentó mayor capacidad predictiva de hemorragia mayor que el basal durante el período de 2-4 años, con mejoras significativas en la sensibilidad y la reclasificación. Se observó un ligero aumento en la sensibilidad del HAS-BLED recalculado a los 4 años respecto al basal.
En pacientes con FA, los riesgos de ictus y hemorragia son dinámicos y cambian con el tiempo. Las escalas CHA2DS2-VASc y HAS-BLED deben revaluarse con regularidad, especialmente para una precisa predicción del riesgo de ictus.
The book Medieval Archaeology of Bled Island is presenting the results of a state-of-the-art archaeological analysis of data from archaeological excavations of the 1962 and 1964.
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.
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 (CHA
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-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 CHA
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-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 CHA
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-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.
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