Assessing bleeding risk
To assess the risk of bleeding it is
necessary to consider factors specific to your patient and the risks associated
with the type of surgery.
Patient factors
A number of patient factors have been
identified which potentially increase the risk of bleeding.
BleedMAP score
In cohort studies of 2182 patients where bleeding complications were monitored for 3 months post surgery, four independent risk factors for bleeding were identified.1 These were the presence of a mitral mechanical heart valve (HR 2.2), active cancer ( HR 1.8), prior bleeding history ( HR2.6) and re-initiation of heparin therapy within 24 h after the procedure (HR 1.9). In patients receiving heparin bridging, thrombocytopenia (<150,000) was also identified as a risk factor with a hazard ratio of 2.3.
On the basis of these predictors the “BleedMAP” scoring system was developed giving a score of 1 point for each of the following: Previous bleed (Bleed), mechanical mitral valve (M), active cancer (A), and thrombocytopenia (P). This score shows a clear correlation with the risk of bleeding; patients with a score of zero had a less than 1% risk of major bleeding whereas patients with a score of 3 or more had a risk of 10%.
Score |
Risk of a major bleed |
Risk category in this App |
0 |
0.81 |
Low |
1 - 2 |
2.67 |
Standard |
> 3 |
10 |
High |
HAS-BLED score
The HAS-BLED score was originally
developed to predict bleeding in patients requiring long-term anticoagulation,
however in a cohort study the score has been shown to predict the risk of
bleeding in patients receiving bridging anticoagulant therapy2. A report from the national online
Bridging registry in Germany
(BORDER) showed that patients with a HAS-BLED score of 3 or more had an
increased risk of bleeding with a hazard ratio of 11.8.
HAS-BLED score
– 1 point for each of the following:
hypertension, abnormal liver or renal function, stroke, bleeding history or
predisposition to bleeding, labile INR, age over 65yrs, medication associated
with bleeding (aspirin/non-steroidals),
high alcohol intake.
Calculating risk
In this application we have assigned levels of risk based on both scoring systems. If either the HAS-BLED score or BleedMAP score is greater than or equal to 3, the patient is catergorised as having a high risk of bleeding; if both scores are 0 the patient has a low risk and all other values are regarded as standard risk.