HAS-BLED
Bleeding Risk on Anticoagulation
≥3 = high risk. Don''t skip anticoag — fix the modifiable factors.
On the AANP exam, anticoagulation in atrial fibrillation hinges on weighing CHA2DS2-VASc against HAS-BLED, and HAS-BLED is the bleed risk side of that conversation. Hypertension uncontrolled (1), Abnormal renal/liver function (1 each), Stroke history (1), Bleeding history or predisposition (1), Labile INR (1), Elderly over 65 (1), Drugs or alcohol (1 each). A score of 3 or higher signals high bleed risk — but never use HAS-BLED to deny anticoagulation in someone who needs it. Use it to flag and modify reversible factors: tighten BP, treat alcohol use, drop concomitant NSAIDs. Boards rewards anticoagulating despite a high score.
- HHypertension (uncontrolled)SBP >160 — modifiable.
- AAbnormal renal or liver function1 point each (dialysis, transplant, cirrhosis, bilirubin >2×, transaminases >3× ULN).
- SStroke historyPrior stroke increases bleeding risk too.
- BBleeding history / predispositionPrior major bleed, anemia, thrombocytopenia.
- LLabile INRApplies only to warfarin — time in therapeutic range <60%.
- EElderly (>65)1 point.
- DDrugs or alcoholAntiplatelets, NSAIDs, chronic alcohol (≥8 drinks/week) — 1 point each.
Clinical Context
A high HAS-BLED score is NOT a reason to withhold anticoagulation in A-fib — the stroke risk typically dominates. Instead, use it as a punch-list: treat HTN, stop NSAIDs, address alcohol, switch labile warfarin to a DOAC.
The AANP commonly pairs CHA₂DS₂-VASc and HAS-BLED in the same stem and asks about anticoagulation decisions. The right answer is almost always "anticoagulate and address modifiable bleeding factors" rather than "don''t anticoagulate."
Related Mnemonics
- 5 T's — Cyanotic Congenital Heart Defects
- 6 P's — Acute Limb Ischemia
- CHA₂DS₂-VASc — Stroke Risk in Non-Valvular Atrial Fibrillation
- MR. PASS MVP — Systolic Murmurs
- MS ARD — Diastolic Murmurs
Sources
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