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."
Practice Questions
A 72-year-old man with newly diagnosed atrial fibrillation is being evaluated for anticoagulation. He reports drinking 10 alcoholic beverages per week and takes daily ibuprofen (Motrin) for chronic knee pain. His blood pressure in clinic today is 172/96 mmHg despite treatment. Which component of the HAS-BLED score does his daily ibuprofen use represent?
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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