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.

  1. Tafur AJ, McBane R, Wysokinski WE et al.  Predictors of major bleeding in peri-procedural anticoagulation management. J Thromb Haemost 2012;10:261-26
  2. Omran H, Bauersachs R, Rubenacker et al. The HAS-BLED score predicts bleeding during bridging of chronic oral anticoagulation. Thromb Hemost 2012; 108: 65-73