Assessment of Bleeding Risk in Antithrombotic Therapy

Introduction to Bleeding Risk Scores

The European Society of Cardiology recommends the use of the HAS-BLED score to assess the risk of bleeding in patients on antithrombotic therapy, including those on aspirin and clopidogrel 1, 2

The HAS-BLED score assesses the risk of major bleeding in patients with atrial fibrillation and on antithrombotic therapy, with components including:

A score of ≥ 3 indicates a high risk of bleeding, requiring more frequent reviews and monitoring 1, 2
Patients with a high score need regular check-ups and monitoring 2

The assessment of bleeding risk should be performed in all patients receiving antithrombotic therapy (with vitamin K antagonists, NOACs, aspirin/clopidogrel, or aspirin) 1
For patients with atrial fibrillation, the risk of bleeding with antiplatelet therapy (with aspirin-clopidogrel combination and, especially in the elderly, also with aspirin monotherapy) should be considered similar to that with oral anticoagulant therapy 1
In patients with a high risk of bleeding (HAS-BLED ≥ 3), reduced doses of NOACs may be considered 1

The HAS-BLED score helps identify modifiable risk factors that need to be addressed, including uncontrolled blood pressure, labile INR, concomitant use of NSAIDs or aspirin in anticoagulated patients, excessive alcohol consumption, and impaired renal or liver function 1, 2, 3

The CRUSADE score was developed for patients with non-ST-elevation myocardial infarction but can be extended to the population with ST-elevation myocardial infarction 3

The risk of bleeding is highly dynamic, requiring assessment at each patient contact 2
A high HAS-BLED score is rarely a reason to avoid anticoagulation but indicates the need for more rigorous monitoring 2
The risk of bleeding increases with the number of antithrombotic agents used, being significantly higher with triple therapy 3, 4
Patients with previous bleeding may benefit from anticoagulants with a lower bleeding risk 2