{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,26]],"date-time":"2026-09-26T13:59:06Z","timestamp":1790431146654,"version":"4.1.0"},"reference-count":38,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2021,11,22]],"date-time":"2021-11-22T00:00:00Z","timestamp":1637539200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Cardiovasc. Med."],"abstract":"<jats:p><jats:bold>Background:<\/jats:bold> Several bleeding risk assessment models have been developed in atrial fibrillation (AF) patients with oral anticoagulants, but the most appropriate tool for predicting bleeding remains uncertain. Therefore, we aimed to assess the diagnostic accuracy of the Hypertension, Abnormal liver\/renal function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly, Drugs\/alcohol concomitantly (HAS-BLED) score compared with other risk scores in anticoagulated patients with AF.<\/jats:p><jats:p><jats:bold>Methods:<\/jats:bold> We comprehensively searched the PubMed and Embase databases until July 2021 to identify relevant pieces of literature. The predictive abilities of risk scores were fully assessed by the C-statistic, net reclassification improvement (NRI) and integrated discrimination improvement (IDI) values, calibration data, and decision curve analyses.<\/jats:p><jats:p><jats:bold>Results:<\/jats:bold> A total of 39 studies met the inclusion criteria. The C-statistic of the HAS-BLED score for predicting major bleeding was 0.63 (0.61\u20130.65) in anticoagulated patients regardless of vitamin k antagonists [0.63 (0.61\u20130.65)] and direct oral anticoagulants [0.63 (0.59\u20130.67)]. The HAS-BLED had the similar C-statistic to the Hepatic or renal disease, Ethanol abuse, Malignancy, Older, Reduced platelet count or function, Re-bleeding risk, Hypertension (uncontrolled), Anemia, Genetic factors, Excessive fall risk, Stroke (HEMORR<jats:sub>2<\/jats:sub>HAGES), the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA), the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT), the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF), or the Age, Biomarkers, Clinical History (ABC) scores, but significantly higher C-statistic than the Congestive heart failure, Hypertension, Age \u226575 years, Diabetes mellitus, Stroke\/transient ischemic attack history (CHADS<jats:sub>2<\/jats:sub>) or the Congestive heart failure\/left ventricular ejection fraction \u2264 40%, Hypertension, Age \u226575 years, Diabetes mellitus, Stroke\/transient ischemic attack\/thromboembolism history, Vascular disease, Age 65\u201374 years, Sex (female) (CHA<jats:sub>2<\/jats:sub>DS<jats:sub>2<\/jats:sub>-VASc) scores. NRI and IDI values suggested that the HAS-BLED score performed better than the CHADS<jats:sub>2<\/jats:sub> or the CHA<jats:sub>2<\/jats:sub>DS<jats:sub>2<\/jats:sub>-VASc scores and had similar or superior predictive ability compared with the HEMORR<jats:sub>2<\/jats:sub>HAGES, the ATRIA, the ORBIT, or the GARFIELD-AF scores. Calibration and decision curve analyses of the HAS-BLED score compared with other scores required further assessment due to the limited evidence.<\/jats:p><jats:p><jats:bold>Conclusion:<\/jats:bold> The HAS-BLED score has moderate predictive abilities for bleeding risks in patients with AF regardless of type of oral anticoagulants. Current evidence support that the HAS-BLED score is at least non-inferior to the HEMORR<jats:sub>2<\/jats:sub>HAGES, the ATRIA, the ORBIT, the GARFIELD-AF, the CHADS<jats:sub>2<\/jats:sub>, the CHA<jats:sub>2<\/jats:sub>DS<jats:sub>2<\/jats:sub>-VASc, or the ABC scores.<\/jats:p>","DOI":"10.3389\/fcvm.2021.757087","type":"journal-article","created":{"date-parts":[[2021,11,22]],"date-time":"2021-11-22T06:03:30Z","timestamp":1637561010000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":76,"title":["Diagnostic Accuracy of the HAS-BLED Bleeding Score in VKA- or DOAC-Treated Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis"],"prefix":"10.3389","volume":"8","author":[{"given":"Xinxing","family":"Gao","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xingming","family":"Cai","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yunyao","family":"Yang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yue","family":"Zhou","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wengen","family":"Zhu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2021,11,22]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"373","DOI":"10.1093\/eurheartj\/ehaa612","article-title":"2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS)","volume":"42","author":"Hindricks","year":"2021","journal-title":"Eur Heart J."},{"key":"B2","doi-asserted-by":"publisher","first-page":"1264","DOI":"10.1093\/eurheartj\/ehu463","article-title":"Clinical outcomes and management associated with major bleeding in patients with atrial fibrillation treated with apixaban or warfarin: insights from the ARISTOTLE trial","volume":"36","author":"Held","year":"2015","journal-title":"Eur Heart J."},{"key":"B3","doi-asserted-by":"publisher","first-page":"1093","DOI":"10.1378\/chest.10-0134","article-title":"novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey","volume":"138","author":"Pisters","year":"2010","journal-title":"Chest."},{"key":"B4","doi-asserted-by":"publisher","first-page":"555","DOI":"10.1002\/clc.22435","article-title":"The HAS-BLED score for predicting major bleeding risk in anticoagulated patients with atrial fibrillation: a systematic review and meta-analysis","volume":"38","author":"Zhu","year":"2015","journal-title":"Clin Cardiol."},{"key":"B5","doi-asserted-by":"publisher","first-page":"791","DOI":"10.1111\/jth.14692","article-title":"Accuracy of HAS-BLED and other bleeding risk assessment tools in predicting major bleeding events in atrial fibrillation: a network meta-analysis","volume":"18","author":"Chang","year":"2020","journal-title":"J Thromb Haemost."},{"key":"B6","doi-asserted-by":"publisher","first-page":"2171","DOI":"10.1055\/s-0038-1675400","article-title":"Predicting thromboembolic and bleeding event risk in patients with non-valvular atrial fibrillation: a systematic review","volume":"118","author":"Borre","year":"2018","journal-title":"Thromb Haemostasis."},{"key":"B7","doi-asserted-by":"publisher","first-page":"788","DOI":"10.1111\/jth.14738","article-title":"Considerations when choosing an appropriate bleeding risk assessment tool for patients with atrial fibrillation","volume":"18","author":"Ding","year":"2020","journal-title":"J Thromb Haemost."},{"key":"B8","doi-asserted-by":"publisher","first-page":"1225","DOI":"10.1161\/STROKEAHA.120.031007","article-title":"Comparative effectiveness and safety of non\u2013vitamin K antagonist oral anticoagulants in atrial fibrillation patients","volume":"52","author":"Zhu","year":"2021","journal-title":"Stroke."},{"key":"B9","doi-asserted-by":"publisher","first-page":"e931","DOI":"10.1136\/openhrt-2018-000931","article-title":"New score for assessing bleeding risk in patients with atrial fibrillation treated with NOACs","volume":"5","author":"Rutherford","year":"2018","journal-title":"Open Heart."},{"key":"B10","doi-asserted-by":"publisher","first-page":"209","DOI":"10.1111\/jcpt.12634","article-title":"Evaluation of the predictive performance of bleeding risk scores in patients with non-valvular atrial fibrillation on oral anticoagulants","volume":"43","author":"Beshir","year":"2018","journal-title":"J Clin Pharm Ther."},{"key":"B11","doi-asserted-by":"publisher","first-page":"931","DOI":"10.1111\/jth.15251","article-title":"Novel bleeding risk score for patients with atrial fibrillation on oral anticoagulants, including direct oral anticoagulants","volume":"19","author":"Adam","year":"2021","journal-title":"J Thromb Haemost."},{"key":"B12","doi-asserted-by":"publisher","first-page":"W1","DOI":"10.7326\/M18-1377","article-title":"A tool to assess risk of bias and applicability of prediction model studies: explanation and elaboration","volume":"170","author":"Moons","year":"2019","journal-title":"Ann Intern Med."},{"key":"B13","doi-asserted-by":"publisher","first-page":"1549","DOI":"10.1016\/j.amjcard.2017.07.051","article-title":"Comparison of the CHA2DS2-VASc, CHADS2, HAS-BLED, ORBIT, and ATRIA risk scores in predicting non-vitamin k antagonist oral anticoagulants-associated bleeding in patients with atrial fibrillation","volume":"120","author":"Yao","year":"2017","journal-title":"Am J Cardiol."},{"key":"B14","doi-asserted-by":"publisher","first-page":"1044","DOI":"10.1016\/j.amjcard.2019.07.005","article-title":"External validation of the ORBIT bleeding score and the HAS-BLED score in non-valvular atrial fibrillation patients using direct oral anticoagulants (Asian Data from the DIRECT Registry)","volume":"124","author":"Mori","year":"2019","journal-title":"Am J Cardiol."},{"key":"B15","doi-asserted-by":"publisher","first-page":"878","DOI":"10.1016\/j.rec.2017.01.021","article-title":"Comparison of bleeding risk scores in patients with nonvalvular atrial fibrillation starting direct oral anticoagulants","volume":"70","author":"Caro","year":"2017","journal-title":"Rev Esp Cardiol."},{"key":"B16","doi-asserted-by":"publisher","first-page":"294","DOI":"10.1016\/j.thromres.2014.05.034","article-title":"The predictive ability of the CHADS2 and CHA2DS2-VASc scores for bleeding risk in atrial fibrillation: the MAQI(2) experience","volume":"134","author":"Barnes","year":"2014","journal-title":"Thromb res."},{"key":"B17","doi-asserted-by":"publisher","first-page":"2199","DOI":"10.1016\/j.jacc.2013.08.1623","article-title":"The HAS-BLED score has better prediction accuracy for major bleeding than CHADS2 or CHA2DS2-VASc scores in anticoagulated patients with atrial fibrillation","volume":"62","author":"Roldan","year":"2013","journal-title":"J Am Coll Cardiol."},{"key":"B18","doi-asserted-by":"publisher","first-page":"697","DOI":"10.1016\/j.amjcard.2016.06.014","article-title":"How well do stroke risk scores predict hemorrhage in patients with atrial fibrillation?","volume":"118","author":"Quinn","year":"2016","journal-title":"Am J Cardiol."},{"key":"B19","doi-asserted-by":"publisher","first-page":"861","DOI":"10.1016\/j.jacc.2012.06.019","article-title":"Performance of the HEMORR(2)HAGES, ATRIA, and HAS-BLED bleeding risk-prediction scores in patients with atrial fibrillation undergoing anticoagulation: the AMADEUS (evaluating the use of SR34006 compared to warfarin or acenocoumarol in patients with atrial fibrillation) study","volume":"60","author":"Apostolakis","year":"2012","journal-title":"J Am Coll Cardiol."},{"key":"B20","doi-asserted-by":"publisher","first-page":"157","DOI":"10.1016\/j.ijcard.2017.11.025","article-title":"Major bleeding and intracranial hemorrhage risk prediction in patients with atrial fibrillation: attention to modifiable bleeding risk factors or use of a bleeding risk stratification score? a nationwide cohort study","volume":"254","author":"Chao","year":"2018","journal-title":"Int J Cardiol."},{"key":"B21","doi-asserted-by":"publisher","first-page":"24376","DOI":"10.1038\/srep24376","article-title":"Major bleeding in patients with non-valvular atrial fibrillation: impact of time in therapeutic range on contemporary bleeding risk scores","volume":"6","author":"Proietti","year":"2016","journal-title":"Sci Rep."},{"key":"B22","doi-asserted-by":"publisher","first-page":"12066","DOI":"10.1038\/s41598-017-11683-2","article-title":"Importance of time in therapeutic range on bleeding risk prediction using clinical risk scores in patients with atrial fibrillation","volume":"7","author":"Rivera-Caravaca","year":"2017","journal-title":"Sci Rep."},{"key":"B23","doi-asserted-by":"publisher","first-page":"179","DOI":"10.1378\/chest.12-0608","article-title":"Predictive value of the HAS-BLED and ATRIA bleeding scores for the risk of serious bleeding in a \u201creal-world\u201d population with atrial fibrillation receiving anticoagulant therapy","volume":"143","author":"Roldan","year":"2013","journal-title":"Chest."},{"key":"B24","doi-asserted-by":"publisher","first-page":"1715","DOI":"10.1111\/jth.13361","article-title":"Bloem-de Vries LM, Verheugt FWA, Brouwer MA. Low performance of bleeding risk models in the very elderly with atrial fibrillation using vitamin K antagonists","volume":"14","author":"Jaspers","year":"2016","journal-title":"J Thromb Haemost."},{"key":"B25","doi-asserted-by":"publisher","first-page":"e009766","DOI":"10.1161\/JAHA.118.009766","article-title":"Predicting bleeding events in anticoagulated patients with atrial fibrillation: a comparison between the HAS-BLED and GARFIELD-AF bleeding scores","volume":"7","author":"Proietti","year":"2018","journal-title":"J Am Heart Assoc."},{"key":"B26","doi-asserted-by":"publisher","first-page":"760","DOI":"10.1161\/CIRCULATIONAHA.118.038312","article-title":"Performance of the ABC scores for assessing the risk of stroke or systemic embolism and bleeding in patients with atrial fibrillation in ENGAGE AF-TIMI 48","volume":"139","author":"Berg","year":"2019","journal-title":"Circulation."},{"key":"B27","doi-asserted-by":"publisher","first-page":"1848","DOI":"10.1160\/TH17-07-0478","article-title":"Long-term bleeding risk prediction in 'real world' patients with atrial fibrillation: comparison of the HAS-BLED and ABC-Bleeding risk scores. The Murcia Atrial Fibrillation Project","volume":"117","author":"Esteve-Pastor","year":"2017","journal-title":"Thromb Haemost."},{"key":"B28","doi-asserted-by":"publisher","first-page":"282","DOI":"10.1111\/joim.12702","article-title":"Comparison of bleeding risk scores in patients with atrial fibrillation: insights from the RE-LY trial","volume":"283","author":"Proietti","year":"2018","journal-title":"J Intern Med."},{"key":"B29","doi-asserted-by":"publisher","first-page":"513","DOI":"10.1016\/j.amjmed.2017.11.046","article-title":"The HAS-BLED, ATRIA, and ORBIT bleeding scores in atrial fibrillation patients using non-vitamin K antagonist oral anticoagulants","volume":"131","author":"Lip","year":"2018","journal-title":"Am J Med."},{"key":"B30","doi-asserted-by":"publisher","first-page":"3258","DOI":"10.1093\/eurheartj\/ehv476","article-title":"The ORBIT bleeding score: a simple bedside score to assess bleeding risk in atrial fibrillation","volume":"36","author":"O'Brien","year":"2015","journal-title":"Eur Heart J."},{"key":"B31","doi-asserted-by":"publisher","first-page":"1074","DOI":"10.1160\/TH13-07-0552","article-title":"Comparison of the CHADS2, CHA2DS2-VASc and HAS-BLED scores for the prediction of clinically relevant bleeding in anticoagulated patients with atrial fibrillation: the AMADEUS trial","volume":"110","author":"Apostolakis","year":"2013","journal-title":"Thromb Haemost."},{"key":"B32","doi-asserted-by":"publisher","first-page":"2302","DOI":"10.1016\/S0140-6736(16)00741-8","article-title":"The novel biomarker-based ABC (age, biomarkers, clinical history)-bleeding risk score for patients with atrial fibrillation: a derivation and validation study","volume":"387","author":"Hijazi","year":"2016","journal-title":"Lancet."},{"key":"B33","doi-asserted-by":"publisher","first-page":"277","DOI":"10.1007\/s10840-014-9930-y","article-title":"Performance of the HAS-BLED high bleeding-risk category, compared to ATRIA and HEMORR2HAGES in patients with atrial fibrillation: a systematic review and meta-analysis","volume":"40","author":"Caldeira","year":"2014","journal-title":"J Interv Card Electrophysiol."},{"key":"B34","doi-asserted-by":"publisher","first-page":"611","DOI":"10.1016\/j.cjca.2019.01.018","article-title":"Importance of risk reassessment in patients with atrial fibrillation in guidelines: assessing risk as a dynamic process","volume":"35","author":"Chang","year":"2019","journal-title":"Can J Cardiol."},{"key":"B35","doi-asserted-by":"publisher","first-page":"768","DOI":"10.1055\/s-0038-1636534","article-title":"Incident risk factors and major bleeding in patients with atrial fibrillation treated with oral anticoagulants: a comparison of baseline, follow-up and delta HAS-BLED scores with an approach focused on modifiable bleeding risk factors","volume":"47","author":"Chao","year":"2018","journal-title":"Thromb Haemostasis."},{"key":"B36","doi-asserted-by":"publisher","first-page":"1195","DOI":"10.1016\/j.amjmed.2020.03.019","article-title":"Regular bleeding risk assessment associated with reduction in bleeding outcomes: the mAFA-II randomized trial","volume":"133","author":"Guo","year":"2020","journal-title":"Am J Med."},{"key":"B37","doi-asserted-by":"publisher","first-page":"n1150","DOI":"10.1136\/bmj.n1150","article-title":"Atrial fibrillation: diagnosis and management-summary of NICE guidance","volume":"373","author":"Perry","year":"2021","journal-title":"BMJ."},{"key":"B38","article-title":"Comparison of HAS-BLED and ORBIT bleeding risk scores in af patients treated with NOACs: a report from the ESC-EHRA EORP-AF general long-term registry","volume-title":"Eur Heart J Qual Care Clin Outcomes","author":"Proietti","year":"2021"}],"container-title":["Frontiers in Cardiovascular Medicine"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fcvm.2021.757087\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,11,22]],"date-time":"2021-11-22T06:03:32Z","timestamp":1637561012000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fcvm.2021.757087\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,11,22]]},"references-count":38,"alternative-id":["10.3389\/fcvm.2021.757087"],"URL":"https:\/\/doi.org\/10.3389\/fcvm.2021.757087","relation":{},"ISSN":["2297-055X"],"issn-type":[{"value":"2297-055X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,11,22]]},"article-number":"757087"}}