Predictive value of the HAS-BLED and ATRIA bleeding scores for the risk of serious bleeding in a ‘real world’ anticoagulated atrial fibrillation population.Roldán V, Marín F, Fernández H, Manzano-Fernandez S, Gallego P, Valdés M, Vicente V, Lip GY. Chest. 2012 Jun 21. [Epub ahead of print] Background.Despite the clear net clinical benefit of oral anticoagulation(OAC) for stroke prevention in atrial fibrillation(AF) patients, the occurrence of major bleeding events may be devastating. The HAS-BLED bleeding risk score (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile INR, elderly and drugs/alcohol concomitantly), was first described in 2010, and is recommended in European and Canadian guidelines to estimate major bleeding risk. In 2011, the ATRIA study group described a new bleeding risk scheme for AF, which includes 5 weighted risk factors: anemia, severe renal disease, age ≥75 years, previous hemorrhage, and diagnosed hypertension. We assessed the predictive value of the ATRIA bleeding score in a large cohort of anticoagulated AF patients, compared with the well-validated HAS-BLED score.Methods.We recruited consecutive anticoagulated AF patients from our out-patient anticoagulation clinic with an INR between 2.0-3.0 during the previous 6 months clinic visits. During follow-up, major bleeding events were assessed. We assessed both bleeding risk scores as quantitative variables or as dichotomized variables (low-moderate vs high risk). Model performance was evaluated by calculating c-statistics, and the improvement in predictive accuracy was evaluated by calculating the net reclassification improvement (NRI) and integrated discrimination improvement (IDI).Results.We included 937 patients (49% male; median age 76). Median (IQR) follow-up was 952(785-1074) days, during which 79(8%) suffered a major bleeding event [annual rate 3.2%). The HAS-BLED score had a similar model performance (based on c-statistics) to the ATRIA score as a quantitative variable (c-statistics 0.71 vs. 0.68, p=0.356), but was superior to the ATRIA score when analysed as a dichotomized variable (c-statistics, 0.68 vs. 0.59, p=0.035). Both NRI and IDI analyses demonstrated that the HAS-BLED score more accurately predicted major bleeding episodes than the ATRIA risk score, as reflected in the percentage of events correctly reclassified.Conclusion.The HAS-BLED score shows significantly better prediction accuracy than the weighted (and more complex) ATRIA score. Our findings reinforce the incremental utility of the simple HAS-BLED score over other published bleeding risk scores in anticoagulated AF patients.