Predictive ability of HAS-BLED, HEMORR2HAGES, and ATRIA bleeding risk scores in patients with atrial fibrillation. A French nationwide cross-sectional study

ObjectiveThe HAS-BLED, ATRIA, and HEMORR2HAGES risk scores were created to evaluate individual bleeding risk in atrial fibrillation (AF). We sought to estimate and compare the predictive ability of these scores for major hemorrhage in AF, including elderly (≥ 80 years) and non-elderly (< 80 years) patients.MethodsThis cross-sectional study is based on the French National Hospital Database (PMSI), which covers the entire French population. Data from all patients with an AF diagnosis in 2012 were extracted. Demographic and comorbidity data were used to calculate the three bleeding risk scores for each patient. Patients hospitalized with a principal diagnosis of major bleeding were identified.ResultsOf the 533,044 AF patients identified, 53.2% were ≥ 80 years; 7013 patients (1.3%) were hospitalized for a bleeding event (1785 for intracranial hemorrhage). Bleeding occurred more frequently in patients with higher HAS-BLED, HEMORR2HAGES, and ATRIA scores. In patients ≥ 80 years, the c-statistics did not differ (p = 0.27) between HAS-BLED (0.54; 95% confidence interval [CI]: 0.53-0.54), HEMORR2HAGES (0.53; 95% CI: 0.53-0.54), and ATRIA (0.53; 95% CI: 0.52-0.54). In patients < 80 years, HAS-BLED (0.59; 95% CI: 0.58-0.60) had a slightly higher c-statistic than HEMORR2HAGES (0.56; 95% CI: 0.55-0.57) and ATRIA (0.55, 95% CI: 0.55-0.56) (p < 0.0001).ConclusionsGiven its simplicity and similar performance, HAS-BLED may be an attractive alternative to HEMORR2HAGES for estimation of bleeding risk in AF patients < 80 years. However, accurate determination of bleeding risk among the elderly is difficult with existing risk-prediction scores, indicating a clear need for improvement in their clinical utility.