Tick the criteria that apply to get the HAS-BLED score out of 9, the major bleeding rate from the cohort it was derived in, and whether the ESC guideline flags it as high risk. For doctors, pharmacists and nurses.
Total 3 of 9 · 3.74 major bleeds per 100 patient-years (high: ESC review flag)
HAS-BLED score
3 of 9
Published band
3.74 major bleeds per 100 patient-years (high: ESC review flag)
1 (hypertension) + 1 (elderly) + 1 (drugs) = 3.
A score of 3 or more is high bleeding risk in the 2020 ESC atrial fibrillation guideline: a reason for earlier and more frequent review, not by itself for withholding anticoagulation.
Modifiable factors ticked: uncontrolled blood pressure, antiplatelets or NSAIDs.
Rates are from the 3,978 people with atrial fibrillation in the Euro Heart Survey (Pisters et al. 2010), over one year.
For doctors, pharmacists and nurses: a published score with its derivation cohort's rates, not a decision about anticoagulation. Verify against current guidelines.
The HAS-BLED criteria
Letter
Criterion
Definition
Points
H
Hypertension
Uncontrolled, systolic above 160 mmHg
1
A
Abnormal renal function
Dialysis, kidney transplant or creatinine ≥ 200 µmol/L (2.26 mg/dL)
1
A
Abnormal liver function
Cirrhosis, or bilirubin > 2 × normal with AST, ALT or ALP > 3 × normal
1
S
Stroke
Previous stroke
1
B
Bleeding
Major bleeding in the past, or a predisposition (such as anaemia or low platelets)
1
L
Labile INR
On warfarin with unstable or high INRs, time in therapeutic range below 60%
1
E
Elderly
Age over 65
1
D
Drugs
Antiplatelet drugs (such as aspirin) or NSAIDs
1
D
Alcohol
8 or more drinks a week
1
Worked example
A 72-year-old with atrial fibrillation, systolic blood pressure of 170 mmHg and taking aspirin: hypertension (1) + elderly (1) + drugs (1) = 3. In the derivation cohort that score had 3.74 major bleeds per 100 patient-years, and the ESC guideline flags it for closer review. Controlling the blood pressure and stopping aspirin if it isn't needed would bring it to 1.
Sources: Pisters R et al. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation. Chest 2010;138:1093-100; 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation (Eur Heart J 2021;42:373-498); 2024 ESC Guidelines for the management of atrial fibrillation. Verify against current guidelines. Everything runs in your browser.
Frequently asked questions
What does HAS-BLED stand for?
Hypertension, Abnormal renal and liver function (1 point each), Stroke, Bleeding history or predisposition, Labile INR, Elderly (over 65), and Drugs or alcohol (1 point each). The total runs from 0 to 9.
What is a high HAS-BLED score?
The 2020 ESC atrial fibrillation guideline treats 3 or more as high bleeding risk, a reason for earlier and more frequent review and for tackling the modifiable factors. The guideline says the bleeding score shouldn't by itself be used to withhold anticoagulation; the 2024 guideline keeps the 3-point flag.
What bleeding rates go with each score?
In the Euro Heart Survey cohort the score was derived from (3,978 people with atrial fibrillation), major bleeds per 100 patient-years were 1.13 at 0, 1.02 at 1, 1.88 at 2, 3.74 at 3 and 8.7 at 4 points; there were too few patients with 5 or more for a rate.
Which risk factors can be changed?
Uncontrolled blood pressure, a labile INR (for example by switching from warfarin where appropriate), antiplatelet drugs or NSAIDs that aren't needed, and alcohol. Age, previous stroke and bleeding history can't, which is why the score is used to target review rather than to decide treatment alone.
How is abnormal kidney or liver function defined?
Kidney: long-term dialysis, a kidney transplant, or creatinine of 200 µmol/L (2.26 mg/dL) or more. Liver: cirrhosis, or bilirubin over twice the upper limit of normal with AST, ALT or ALP over three times it.
