Bleeding risk scores such as HAS-BLED were designed to flag modifiable risk, not to decide who gets anticoagulation. A patient whose stroke risk warrants a DOAC and who also scores high for bleeding usually does better with the anticoagulant and closer attention to the reasons they might bleed.
The modifiable items are the ones to act on: uncontrolled blood pressure, concurrent antiplatelet or NSAID use, excess alcohol, labile INR on warfarin, and unrecognised anaemia or renal impairment that should shape the dose.
- Control blood pressure before and during anticoagulation.
- Stop an antiplatelet or NSAID that has no clear current indication.
- Ask about alcohol and check haemoglobin and creatinine at baseline.
- Dose DOACs to weight, age and renal function as labelled, and recheck yearly.
Why it matters
Withholding a DOAC because of a score leaves the stroke risk untouched and the fixable bleeding risk unfixed.
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