The HEMORR₂HAGES score was developed to quantify the risk of hemorrhage in patients with atrial fibrillation on anticoagulation and to aid in the management of antithrombotic therapy. For patients on warfarin found that HEMORR₂HAGES was more discriminatory compared to the other scores systems.

Patient’s score	Points	Risk of bleeding
0	0	0

The HEMORR₂HAGES scoring system consists of eleven criteria, one of which (history of prior bleeding) is worth 2 points, while the other ten are worth 1 point each.

The HEMORR₂HAGES scoring system combines components from several other previously validated bleeding risk scores into one.

Addition of the selected points, see below:

Criteria	Points
Hepatic or renal disease	+1
Ethanol abuse	+1
Malignancy	+1
Older (age > 75)	+1
Reduced platelet count or function	+1
Rebleeding (Prior Bleed)	+2
Hypertension (uncontrolled)	+1
Anemia	+1
Genetic factors (CYP 2C9 single-nucleotide polymorphisms)	+1
Excessive fall risk, dementia, Parkinson’s disease, or psychiatric disease	+1
Stroke	+1

Results interpretation:

Points	Risk of bleeding
0-1	Low-risk group
2-3	Intermediate-risk group
≥4	High-risk group

Risk of bleeding in patients on warfarin:

Points	Risk of bleeding	Recommendation
0 points	1.9% risk of bleeding per 100 patient-years of warfarin.	Consider initiation of warfarin therapy if clinically indicated as risk of thrombotic events likely outweighs the risk of bleeding.
1 points	2.5% risk of bleeding per 100 patient-years of warfarin.	Consider initiation of warfarin therapy if clinically indicated as risk of thrombotic events likely outweighs the risk of bleeding.
2 points	5.3% risk of bleeding per 100 patient-years of warfarin.	Consider alternatives to anticoagulation unless strong indications for warfarin therapies exist.
3 points	8.4% risk of bleeding per 100 patient-years of warfarin.	Consider alternatives to anticoagulation unless strong indications for warfarin therapies exist.
4 points	10.4% risk of bleeding per 100 patient-years of warfarin.	Alternative options should often be considered in patients with high-risk of major bleeding events in need of anticoagulation.
5-12 points	12.3% risk of bleeding per 100 patient-years of warfarin.	Alternative options should often be considered in patients with high-risk of major bleeding events in need of anticoagulation.

Study found that the number of bleeds per 100 patient-years of warfarin increased as their HEMORR₂HAGES score increased. A subsequent systemic review and meta-analysis comparing the performance of HAS-BLED, ATRIA and HEMORR₂HAGES recommended HAS-BLED for the assessment of atrial fibrillation patients’ major bleeding risk. The analysis found that HEMORR₂HAGES had a higher diagnostic accuracy, but considered it difficult to use due to its complexity.

The genetic risk factor was included in their score, but not actually tested in their cohort of patients.

HAS-BLED Score compare with the HEMORR₂HAGES Score has greater sensitivity,  HEMORR₂HAGES Score has greater specificity then HAS-BLED Score.

Risks and benefits of anticoagulation should be carefully considered in all patients with atrial fibrillation prior to initiating therapy.

Other risk stratification scores such as HAS-BLED or ATRIA should also be taken into consideration prior to starting anticoagulation.

 

Literature:
Gage BF, Yan Y, Milligan PE, et al. Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillation. Am Heart J 2006; 151:713-9. https://pubmed.ncbi.nlm.nih.gov/16504638/
Stavros Apostolakis, MD, PhD, Deirdre A. Lane, PhD, Yutao Guo, MD, Harry Buller, MD, PhD, Gregory Y.H. Lip, MD Performance of the HEMORR https://www.jacc.org/doi/10.1016/j.jacc.2012.06.019?articleid=1305797&
Caldera D, Costa J, Fernandes RM, et al. Performance of the HAS-BLED high bleeding-risk category, compared to ATRIA and HEMORR https://pubmed.ncbi.nlm.nih.gov/25012972/

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