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HEMORR₂HAGES Score for Major Bleeding Risk
Estimates major bleeding risk in elderly patients on anticoagulation for atrial fibrillation.
HEMORR₂HAGES Score for Major Bleeding Risk
Hepatic or renal disease
Chronic liver disease or dialysis-dependent/significant renal impairment.
Ethanol (alcohol) abuse
Malignancy
Prior diagnosis at any time, or newly diagnosed.
Age >75 years
Reduced platelet count or function
e.g. thrombocytopenia or concurrent antiplatelet therapy.
Prior bleeding episode (rebleeding risk)
History of a major or clinically relevant bleed.
Uncontrolled hypertension
Anemia
Genetic factors associated with bleeding (e.g. CYP2C9 polymorphism)
Only include if genotyping is known.
Excessive fall risk
e.g. gait instability, neurologic disease, severe frailty.
Prior stroke
Result0 points
Approximate major bleeding rate of 1.9 per 100 patient-years in the derivation cohort.
- Reported bleed rate
- 1.9 per 100 patient-years
When to use
- Estimating major hemorrhage risk before starting or continuing anticoagulation for atrial fibrillation.
- Weighing bleeding risk against stroke-prevention benefit alongside a stroke risk score (e.g. CHA2DS2-VASc).
Formula
Sum of 11 factors: Hepatic/renal disease, Ethanol abuse, Malignancy, Older age (>75), Reduced platelet count/function, Rebleeding (prior bleed, worth 2 points), Hypertension (uncontrolled), Anemia, Genetic factors (CYP2C9), Excessive fall risk, Stroke. Each factor scores 1 point except rebleeding, which scores 2. Range 0-12.
Pearls and pitfalls
- Derived and validated in the National Registry of Atrial Fibrillation; the genetic (CYP2C9) item is often omitted in practice because genotyping is not routinely available.
- A higher score should prompt closer bleeding-risk mitigation (e.g. blood pressure control, fall prevention, avoidance of concurrent antiplatelets) rather than automatic withholding of anticoagulation.