This calculator is for general information and education. It is not medical advice and does not replace the judgment of a doctor, nurse or pharmacist who knows the full clinical picture.
HEMORR₂HAGES is one of the first bleeding risk scores built for people with atrial fibrillation on blood thinners. Published by Gage and colleagues in 2006, it was derived from about 3,800 Medicare patients in the National Registry of Atrial Fibrillation. Each letter of its name stands for a risk factor.
The score
| Letter | Risk factor | Points |
|---|---|---|
| H | Hepatic or renal disease | 1 |
| E | Ethanol (alcohol) abuse | 1 |
| M | Malignancy | 1 |
| O | Older age (over 75) | 1 |
| R | Reduced platelet count or function, including aspirin | 1 |
| R₂ | Rebleeding risk: prior major bleed | 2 |
| H | Hypertension, uncontrolled | 1 |
| A | Anemia | 1 |
| G | Genetic factors (CYP2C9 variants) | 1 |
| E | Excessive fall risk | 1 |
| S | Stroke | 1 |
The total ranges from 0 to 12.
Example
An 80-year-old with uncontrolled high blood pressure and no other risk factor scores 1 + 1 = 2.
Bleeding rates in the original study
| Score | Bleeds per 100 patient-years on warfarin |
|---|---|
| 0 | 1.9 |
| 1 | 2.5 |
| 2 | 5.3 |
| 3 | 8.4 |
| 4 | 10.4 |
| 5 or more | 12.3 |
A score of 0 or 1 is usually read as low risk, 2 or 3 as intermediate and 4 or more as high.
Which score to use?
HEMORR₂HAGES is detailed but needs information that is rarely available, such as CYP2C9 genetic testing. HAS-BLED is simpler, performs at least as well and is the one recommended by European guidelines. The ATRIA score is another alternative. All of them predict bleeding only moderately well, so they guide follow-up rather than decide treatment.
How to use the result
A high bleeding score does not mean anticoagulation should be stopped; for most people the benefit in stroke prevention is greater. It points to factors to correct, such as blood pressure, alcohol, aspirin or anti-inflammatory drugs, anemia and fall risk, and to closer monitoring. Talk to your doctor before changing any blood thinner.