UPDATE IN OFFICE MANAGEMENT

Implications of the CHA2DS2-VASc and HAS-BLED Scores

for Thromboprophylaxis in Atrial Fibrillation
Gregory Y. H. Lip, MD
University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, England, UK.

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 ⱖ75 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 ⱖ1), 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 ⱖ3 indicates
“high risk” and some caution and regular review of the patient is needed, following the initiation of antithrom-
botic therapy, whether with oral anticoagulation or antiplatelet therapy.
© 2011 Elsevier Inc. All rights reserved. • The American Journal of Medicine (2011) 124, 111-114

KEYWORDS: Atrial fibrillation; Bleeding; Risk stratification scheme; Stroke

Patients with atrial fibrillation are well established to be at risk
for stroke and thromboembolism, and numerous clinical trials
have led to guideline recommendations on thromboprophy-
laxis. These guidelines have (artificially) categorized stroke
risk into ‘high’, ‘moderate’ or ‘low’ risk strata according to
various risk factors for stroke and thromboembolism derived
from nonwarfarin arms of clinical trial cohorts and cohort
studies.1 Based on schemes such as the CHADS2 (Congestive
heart failure, Hypertension, Age ⱖ75 years, Diabetes mellitus,
Stroke) score (Table 1)2,3, guidelines have largely recom-
mended “oral anticoagulation” for “high risk” patients
(CHADS2 score ⱖ2), and “aspirin” for those at “low risk”
(CHADS2 score ⫽ 0); while “oral anticoagulation or aspirin” is
Funding: None.
Conflict of Interest: Dr. Lip has received funding for research, edu-
cational 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.
Requests for reprints should be addressed to Gregory Y. H. Lip, MD,
University of Birmingham Centre for Cardiovascular Sciences, City Hos-
pital, Birmingham B18 7QH, England, UK.
E-mail address: g.y.h.lip@bham.ac.uk.
recommended for “moderate/intermediate risk” atrial fibrilla-
tion patients (CHADS2 score ⫽ 1).
With current oral anticoagulation drugs— essentially the
vitamin K antagonists (eg, warfarin)—widespread usage con-
fers the inconvenience of anticoagulation monitoring, as well
as various drug/alcohol/diet/lifestyle limitations and potential
bleeding risk. The latter is multifactorial, but is also intimately
related to quality of anticoagulation control4 and poor time-in-
therapeutic range, and is associated with poorer outcomes.5
The bleeding risk with antiplatelet therapy is similar to that
with warfarin, especially in the elderly.6
HOW CAN WE ASSESS BLEEDING RISK?
Many risk factors for stroke are also risk factors for bleed-
ing.7 Furthermore, previously published schemes for bleed-
ing 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 varying predictive values (as well

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112 The American Journal of Medicine, Vol 124, No 2, February 2011

Table 1 Stroke Risk Stratification with the CHADS2 and

was even superior predictive ability for major bleeding (with
CHA2DS2-VASc Scores c-statistics of 0.91 and 0.85, respectively).

CHADS2 Adjusted Stroke

CHADS2 Acronym Score Score Rate (%/Year)* HOW WOULD A SIMPLE, EASY SCORE IN
Congestive heart failure 1 0 1.9% ASSESSING BLEEDING RISK HELP OFFICE
Hypertension 1 1 2.8% MANAGEMENT OF ATRIAL FIBRILLATION
Aged ⱖ75 years 1 2 4.0% PATIENTS?
Diabetes mellitus 1 3 5.9%
Recent data have shown that even in “moderate risk” pa-
Stroke/TIA/TE 2 4 8.5%
tients (ie, CHADS2 score ⫽ 1), oral anticoagulation is supe-
5 12.5%
Maximum score 6 6 18.2% rior to aspirin for stroke and mortality prevention,13 and
among “low risk” atrial fibrillation patients (ie, CHADS2
CHA2DS2-VASc Adjusted Stroke score ⫽ 0), aspirin may be no better than control for the
CHA2DS2-VASc Acronym Score Score Rate (%/Year)†
reduction of thromboembolism, with a risk of increased
Congestive heart 1 0 0 bleeding.14 When aspirin alone was compared with placebo
failure/LV dysfunction or no treatment in 7 trials, a meta-analysis showed that
Hypertension 1 1 0.7% aspirin was associated with a non-significant 19% (95%
Aged ⱖ75 years 2 2 1.9% confidence interval, ⫺1% to -35%) reduction in the inci-
Diabetes mellitus 1 3 4.7%
dence of stroke.15 The only clinical trial (Stroke Prevention
Stroke/TIA/TE 2 4 2.3%
Vascular disease (prior 1 5 3.9%
in Atrial Fibrillation-I) showing a positive effect of aspirin
MI, PAD, or aortic on stroke (relative risk reduction, 42% reduction overall)
plaque) had internal heterogeneity, with inconsistencies for the as-
Aged 65-74 years 1 6 4.5% pirin effect between the results for the warfarin-eligible
Sex category (ie, 1 7 10.1% (relative risk reduction, 94%) and warfarin-ineligible (rela-
female sex) tive risk reduction, 8%) arms of the trial.16 In the Birming-
Maximum score 9 8 14.2% ham Atrial Fibrillation Treatment of the Aged trial,6 war-
9 100% farin was superior to aspirin for stroke prevention, with no
LV ⫽ left ventricular; MI ⫽ myocardial infarction; PAD ⫽ peripheral difference in major bleeding rates between warfarin and
artery disease; TE ⫽ thromboembolism; TIA ⫽ transient ischemic attack. aspirin in a primary care elderly atrial fibrillation popula-
*Based on Gage et al;2 these stroke rates are based on data on
hospitalized atrial fibrillation patients and published in 2001. Given that
tion. Thus, the indication for oral anticoagulation for stroke
stroke rates are declining, actual rates of stroke in contemporary non- prevention in atrial fibrillation is likely to be much broader,
hospitalized cohorts may vary from these estimates. and the role (or value) of aspirin less defined.
†Based on initial validation cohort reported by Lip et al17actual rates Given these data, it is clear that practicing physicians
of stroke in contemporary cohorts may vary from these estimates.
need a paradigm shift so that stroke risk assessment would
be better in finding those patients who are truly at low risk.
However, the CHADS2 score has many limitations and does
as clinical applicability) of some of these scores have lim- not include some risk factors for thromboembolism, hence,
ited their widespread application. Also, schemes derived the evolution of more refined stroke risk stratification
from a “general” anticoagulated population may not neces- schemes to complement the CHADS2 score by the addition
sarily be reflective of an atrial fibrillation population, which of ‘stroke risk modifier’ risk factors, such as the new
is often older with associated comorbidities and concomi- CHA2DS2-VASc (Congestive heart failure/left ventricle
tant multiple drug therapies. There is, therefore, the need for dysfunction, Hypertension, Age ⱖ75 years, Diabetes mel-
a simple, practical risk stratification scheme for the predic- litus, Stroke, Vascular disease, Age 65-74 years, Sex cate-
tion of major hemorrhage during anticoagulant therapy that gory) score (Table 1).17 The latter scheme identifies “truly
has been derived and prospectively evaluated in a “real low risk” atrial fibrillation patients as those with a
world” atrial fibrillation population. CHA2DS2-VASc score ⫽ 0, who can probably be treated
Using a “real world” cohort of 3978 European subjects with no antithrombotic therapy. All others (ie, CHA2DS2-
with atrial fibrillation, a new bleeding risk score (acronym VASc score ⱖ1], can be considered for oral anticoagula-
HAS-BLED: Hypertension, Abnormal renal/liver function, tion.3,17 A simple bleeding risk assessment can clearly help
Stroke, Bleeding history or predisposition, Labile International guide management here. For example, it would seem rea-
Normalized Ratio, Elderly [eg. aged ⬎65 years], Drugs/alco- sonable to use the HAS-BLED score as a calculation to
hol concomitantly) has been proposed (Table 3).12 This new assess bleeding risk in atrial fibrillation patients, whereby a
simple bleeding risk score (HAS-BLED) gave similar c-statis- score of ⱖ3 indicates “high risk” and some caution and
tics to the HEMORR2HAGES scheme in an overall validation regular review of the patient is needed following the initi-
cohort (0.72), but in some patient subgroups, who were receiv- ation of antithrombotic therapy, whether with oral antico-
ing antiplatelet agents alone or no antithrombotic therapy, there agulation or aspirin.
Lip Stroke and Bleeding Risk in Atrial Fibrillation 113

Table 2 Contemporary Bleeding Risk Stratification Schema

Low Moderate High Calculation of Bleeding Risk Score

Kuijer et al 11
0 1-3 ⬎3 (1.6 ⫻ age) ⫹ (1.3 ⫻ sex) ⫹ (2.2 ⫻ cancer) with 1 point for
ⱖ60, female, or malignancy, and 0 if none
Beyth et al10 0 1-2 ⱖ3 ⱖ65 years old; GI bleed in last 2 weeks; previous stroke;
comorbidities (recent MI, Hct ⬍30%, diabetes, creatinine ⬎1.5
ml/L) with 1 point for presence of each condition and 0 if absent
Gage et al9 0-1 2-3 ⱖ4 HEMORR2HAGES score: liver/renal disease, ETOH abuse, malignancy,
⬎75 years old, low platelet count or function, rebleeding risk,
uncontrolled hypertension, anemia, genetic factors (eg. CYP2C9),
risk for fall or stroke, with 1 point for each risk factor present
with 2 points for previous bleed
Shireman et al8 ⱕ1.07 ⬎1.07-⬍2.19 ⬎2.19 (0.49 ⫻ age ⬎70) ⫹ (0.32 ⫻ female) ⫹ (0.58 ⫻ remote bleed) ⫹
(0.62 ⫻ recent bleed) ⫹ (0.71 ⫻ alcohol/drug abuse) ⫹ (0.27 ⫻
diabetes) ⫹ (0.86 ⫻ anemia) ⫹ (0.32 ⫻ antiplatelet drug use)
with 1 point for presence of each, and 0 if absent
Pisters et al12 0 1-2 ⱖ3 Birmingham AF bleeding score: hypertension, abnormal renal/liver
function (1 point each), stroke, bleeding history or
predisposition, labile INR, elderly, drugs/alcohol concomitantly
(1 point each). Maximum 9 points.
AF ⫽ atrial fibrillation; ETOH ⫽ alcohol; GI ⫽ gastrointestinal; Hct ⫽ haematocrit; INR ⫽ international normalized ratio; MI ⫽ myocardial infarction.

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 antico-
agulants that avoid some of the limitations and disadvan-
tages of warfarin. In the RE-LY (Randomized Evaluation of
Long-term anticoagulant therapY) trial, for example, dabig-
atran 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 effi-
cacy for stroke prevention compared with warfarin, with a
similar rate of major bleeds.18 The simplification of stroke
risk assessment (eg, with the CHA2DS2-VASc score, where
“0 ⫽ nothing,” and a score of score ⱖ1 means “treat”) with
a practical bleeding risk assessment (HAS-BLED) would
guide office management, should both doses of dabigatran
ultimately receive a license for stroke prevention in atrial
fibrillation.
In gazing into the future—assuming US Food and Drug
Administration approval of the new oral anticoagulants—
when atrial fibrillation patients have a CHA2DS2-VASc
score ⱖ1, physicians should consider oral anticoagulation
with dabigatran etexilate (or other agent, depending on their

Table 3 Clinical Characteristics Comprising the HAS-BLED Bleeding Risk Score

Bleeds per 100

Letter Clinical Characteristic* Score HAS-BLED Score Patient-years†
H Hypertension 1 0 1.13
A Abnormal renal and liver function (1 point each) 1 or 2 1 1.02
S Stroke 1 2 1.88
B Bleeding 1 3 3.74
L Labile INRs 1 4 8.70
E Elderly 1
D Drugs or alcohol (1 point each) 1 or 2
Maximum 9 points
*“Hypertension” is defined as systolic blood pressure ⬎160 mm Hg. “Abnormal kidney function” is defined as the presence of chronic dialysis or renal
transplantation or serum creatinine ⱖ200 ␮mol/L. “Abnormal liver function: is defined as chronic hepatic disease (eg, cirrhosis) or biochemical evidence
of significant hepatic derangement (eg, bilirubin ⬎2⫻ upper limit of normal, in association with aspartate transaminase/alanine transaminase/alkaline
phosphatase ⬎3⫻ upper limit normal). “Bleeding” refers to previous bleeding history or predisposition to bleeding (eg, bleeding diathesis, anemia).
“Labile INRs” refers to unstable/high international normalized ratios or poor time in therapeutic range (eg, ⬍60%). Drugs/alcohol use refers to
concomitant use of drugs, such as antiplatelet agents and nonsteroidal anti-inflammatory drugs.
†Based on initial validation cohort reported by Pisters et al,12 with insufficient events at HAS-BLED scores ⱖ5 to give rates; actual rates of stroke in
contemporary cohorts may vary from these estimates.
114
trial data), as an alternative to adjusted dose warfarin ther-
apy. If the patient is at low bleeding risk (eg, HAS-BLED
score of 0-2), dabigatran etexilate 150 mg twice daily (or
other agent, depending on their trial data) could be consid-
ered, in view of potentially superior efficacy in the preven-
tion of thromboembolism (but lower rates of intracranial
hemorrhage and similar major bleeding rates), when com-
pared with warfarin. However, if a patient has a measurable
risk of bleeding (eg, HAS-BLED score of ⱖ3), dabigatran
etexilate 110 mg twice daily (or other agent, depending on
their trial data) could be considered, in view of a similar
efficacy in the prevention of thromboembolism, but lower
rates of both intracranial hemorrhage and major bleeding
compared with warfarin. In patients with CHA2DS2-VASc
score ⫽ 1, dabigatran etexilate 110 mg twice daily (or other
agent, depending on their trial data) could perhaps be con-
sidered, in view of similar efficacy to vitamin K antagonist
in the prevention of thromboembolism, but with lower rates
of intracranial hemorrhage and major bleeding compared
with warfarin and (probably) aspirin. Finally, patients with
CHA2DS2-VASc score ⫽ 0 are clearly at so low a risk,
either aspirin 75-325 mg daily or no antithrombotic therapy
is recommended, but where possible, no antithrombotic
therapy could even be preferred for such “truly low risk”
patients—rather than aspirin— given the lack of demonstra-
ble benefit and potential for harm from bleeding with aspirin
in this population.14
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