In patients with a high bleeding risk, all bleeding risk factors should be identified and modifiable risk factors should be addressed.5,6,7
Based on risk factors included in the HAS-BLED score, and other bleeding risk clinical scores (HEMORR2HAGES, ATRIA, ORBIT, ABC), modifiable bleeding risk factors include:5
- hypertension (especially when systolic blood pressure is > 160 mmHg)
- labile INR or time in therapeutic range < 60% (in patients taking warfarin)
- medicines that may predispose to bleeding (such as antiplatelet medicines or NSAIDs)
- excessive alcohol consumption (typically ≥ 8 drinks/week).
Potentially modifiable bleeding risk factors include:5
- impaired kidney function
- reduced platelet count or function.
Non-modifiable bleeding risk factors include:5
- age > 65 years, or ≥ 75 years
- history of major bleeding
- previous stroke
- dialysis-dependent kidney disease or kidney transplant
- cirrhotic liver disease
- genetic factors.
Overall, stroke and bleeding risk should be assessed on a patient-by-patient basis when considering an oral anticoagulant, but assessment of bleeding and other risks should continue throughout treatment.9 -13
All patients should be educated about the benefits and risks associated with anticoagulant medicines, so they can contribute to management decisions.
For example, some patients may accept a higher risk of bleeding, knowing that they are avoiding a stroke.