|
We recently developed a clinical
prediction rule and acronym for major bleeding,
HEMORR2HAGES (Table 1).
To develop this scheme, we combined bleeding risk factors from existing
classification schemes into a new clinical prediction rule (Table 2). We scored
HEMORR2HAGES by adding 2 points for a prior bleed and 1 point for
each of the other risk factors (Table 2). We
quantified the risk of bleeding using Medicare data from 3791 Medicare
beneficiaries with atrial fibrillation:
Table
1.
Incidence
of Major Bleeds in National Registry of Atrial
Fibrillation
|
HEMORR2HAGES
Score
|
N
|
N
of Bleeds
|
Bleeds
per 100 pt-yrs warfarin (95% CI)
|
|
0
|
209
|
4
|
1.9
(0.6-4.4)
|
|
1
|
508
|
11
|
2.5
(1.3-4.3)
|
|
2
|
454
|
20
|
5.3
(3.4-8.1)
|
|
3
|
240
|
15
|
8.4
(4.9-13.6)
|
|
4
|
106
|
9
|
10.4
(5.1-18.9)
|
|
≥
5
|
87
|
8
|
12.3
(5.8-23.1)
|
N = number; pt-yrs = patient-years.
Adapted from
Gage
BF et al. Clinical classification schemes
for predicting hemorrhage: Results from the National Registry of Atrial
Fibrillation (NRAF).
Am Heart J 2006;151:713-9.
Table 2.
Independent bleeding-risk factors (and points)
|
HEMORR2HAGES
Risk Factors (score)
|
Definition
|
|
Hepatic (1)
or renal disease
(1)
|
Hepatic
disease: cirrhosis, two-fold or greater elevation of AST or APT, or albumin
< 3.6 g/dL
Renal insufficiency: Cr
clearance < 30 ml/min
|
|
Ethanol use (1)
|
History
of alcohol abuse, recent hospitalization for alcohol-related illness, and
worsening liver disease
|
|
Malignancy (1)
|
Recent
metastatic cancer
|
|
Older (age >
75) (1)
|
Calculated
from birth date
|
|
Reduced platelet
count
(1) or
function (1)
|
Platelets
< 75,000
Schedule use of antiplatelet therapy (e.g. daily aspirin) or NSAID therapy; or
blood dyscrasia
|
|
Re-Bleeding (2)
|
Prior
hospitalization bleeding
|
|
Hypertension, uncontrolled
(1)
|
Blood
pressure not currently in control: most recent systolic bp > 160 torr
|
|
Anemia (1)
|
Most recent hematocrit <
30 or hemoglobin < 10
g/dL
|
|
Genetic factors (1)
|
CYP2C9*2
and/or CYP2C9*3
|
|
Elevated risk of
fall including neuropsychiatric
disease (1)
|
Alzheimer's
dementia, Parkinson's disease, schizophrenia, or any condition predisposing to
repeated falls
|
|
Stroke (1)
|
Prior
ischemic stroke or brain infarct detected by brain imaging
|
Cr = creatinine; AST = aspartate transaminase (also
called serum glutamic oxaloacetic);
ALT = aspartate transaminase (also called serum glutamate pyruvate
transaminase); NSAID = Non steroidal anti-inflammatory drugs, excluding
cyclooxygenase II-specific inhibitors; bp = blood pressure; CYP2C9*2 and/or
CYP2C9*3 genotypes were not included in the original scheme.
|