HEMORR₂HAGES Score for Major Bleeding Risk On-line calculator

HEMORR₂HAGES Score for Major Bleeding Risk On-line calculator

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.

Hepatic or Renal Disease:
No
Yes

Ethanol (Alcohol) Abuse:
No
Yes

Malignancy History:
No
Yes

Older (Age > 75):
No
Yes

Reduced Platelet Count or Function
Includes aspirin use, any thrombocytopenia or blood dyscrasia, like hemophilia:

No
Yes

Rebleeding Risk (history of past bleeding):
No
Yes

Hypertension (Uncontrolled):
No
Yes

Anemia (Hgb<13 g/dL for Men; Hgb <12 g/dL for Women):
No
Yes

Genetic Factors (CYP 2C9 single-nucleotide polymorphisms):
No
Yes

Excessive Fall Risk, dementia, Parkinson’s disease, or psychiatric disease:
No
Yes

Stroke History:
No
Yes



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:

CriteriaPoints
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:

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

Risk of bleeding in patients on warfarin:

PointsRisk of bleedingRecommendation
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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Charlson Comorbidity Index (CCI) Online Calculator

Charlson Comorbidity Index predicts 10-year survival in patients with multiple comorbidities.

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History of definite or probable MI (EKG changes and/or enzyme changes)

Exertional or paroxysmal nocturnal dyspnea and has responded to digitalis, diuretics, or afterload reducing agents

Intermittent claudication or past bypass for chronic arterial insufficiency, history of gangrene or acute arterial insufficiency, or untreated thoracic or abdominal aneurysm (≥6 cm)

History of a cerebrovascular accident with minor or no residua and transient ischemic attacks

Chronic cognitive deficit

Any history of treatment for ulcer disease or history of ulcer bleeding

Severe = cirrhosis and portal hypertension with variceal bleeding history, moderate = cirrhosis and portal hypertension but no variceal bleeding history, mild = chronic hepatitis (or cirrhosis without portal hypertension)

Severe = on dialysis, status post kidney transplant, uremia, moderate = creatinine >3 mg/dL (0.27 mmol/L)


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