HAS-BLED (risco sangramento)

HAS-BLED: bleeding risk on oral anticoagulation

The HAS-BLED estimates the annual risk of major bleeding in patients on oral anticoagulation, most often in the setting of atrial fibrillation. Each item scores 1 point unless noted otherwise: Hypertension uncontrolled (SBP >160), Abnormal renal function (1) and/or hepatic function (1), Stroke prior, Bleeding history or predisposition, Labile INR (TTR <60%), Elderly >65 years, Drugs (antiplatelets/NSAIDs) (1) and/or alcohol abuse (1). The total runs from 0–9. Reading it: 0–2 low/moderate risk, ≥3 high risk, which calls for closer monitoring but does not contraindicate anticoagulation. Example: a 70-year-old hypertensive (uncontrolled) patient on aspirin scores 1+1+1 = 3 → high risk, so step up the follow-up.

Clinical context

It was validated in 2010 (Pisters et al.) and has since been adopted by the ESC and the Brazilian Society of Cardiology. You use it alongside CHA2DS2-VASc, never in place of it. Where the score really earns its keep is in flagging reversible factors: getting blood pressure under control, cutting alcohol, revisiting concomitant NSAIDs and antiplatelets, tightening INR control. It fits patients on warfarin or DOACs, AF clinics, post-thromboembolism follow-up, and the call on whether to combine antiplatelet with anticoagulant therapy.

FAQ

Does HAS-BLED ≥3 contraindicate anticoagulation? No. It tells you bleeding risk is elevated, so reversible factors need attention and monitoring should be tighter. It is not a reason to withhold anticoagulation that CHA2DS2-VASc indicates.

Does the labile INR criterion apply to DOACs? No. It applies only to warfarin (TTR <60% over the last 6 months). With DOACs, leave this item out.

What counts as renal/hepatic abnormality? On the renal side: creatinine >2.26 mg/dL, dialysis, or transplant. On the hepatic side: cirrhosis, or bilirubin >2× normal together with AST/ALT >3× normal.

How often should I reassess? At least once a year, and again after any clinically relevant change such as a new medication, declining kidney function, or a hospitalization.