Thromboembolic And Anticoagulation Scores

HEMORR₂HAGES Bleeding Risk Score Calculator – Anticoagulation in Atrial Fibrillation

Clinical calculation support · Verify results before clinical use

Bleeding Risk Assessment

Select each clinical factor present. Previous bleeding contributes 2 points; all other factors contribute 1 point.

0Score
H

Hepatic or renal disease

Presence of hepatic disease or renal disease. This is a single combined criterion (maximum 1 point).

+1 point
E

Ethanol abuse

History or current clinical assessment indicating alcohol abuse.

+1 point
M

Malignancy

Known malignancy.

+1 point
O

Older age (>75 years)

Age strictly greater than 75 years, following the original derivation paper.

+1 point
R

Reduced platelet count or function

Thrombocytopenia or impaired platelet function.

+1 point
R₂

Rebleeding risk / previous bleeding

History of prior bleeding; this criterion is weighted twice.

+2 points
H

Hypertension (uncontrolled)

Uncontrolled hypertension.

+1 point
A

Anemia

Presence of anemia.

+1 point
G

Genetic factors (CYP2C9)

Relevant CYP2C9 genetic variant(s), as assessed by testing or documented history.

+1 point
E

Excessive fall risk

Clinically assessed excessive risk of falling.

+1 point
S

Stroke

History of stroke.

+1 point
0HEMORR₂HAGES
Bleeding risk category
Low Risk
Original warfarin cohort: 1.9 major bleeding events per 100 patient-years.
Clinical interpretationScore 0–1: low-risk category in published HEMORR₂HAGES classification. Review and address individual bleeding risk factors as clinically appropriate.

The incidence figures are from the original warfarin-treated derivation cohort and are not individualized contemporary estimates, particularly for patients receiving direct oral anticoagulants.

About the HEMORR₂HAGES Score

HEMORR₂HAGES is a clinical bleeding-risk classification developed for patients with atrial fibrillation. It combines 11 clinical risk factors. Each factor contributes 1 point, except previous bleeding, which contributes 2 points. The total score ranges from 0 to 12.

Variables and points

Risk factorPoints
Hepatic or renal disease1
Ethanol abuse1
Malignancy1
Older age (>75 years)1
Reduced platelet count or function1
Rebleeding risk / previous bleeding2
Hypertension (uncontrolled)1
Anemia1
Genetic factors (CYP2C9)1
Excessive fall risk1
Stroke1

Risk category and original cohort incidence

Total scoreCategoryMajor bleeding incidence*
0–1Low1.9–2.5 per 100 patient-years
2–3Moderate5.3–8.4 per 100 patient-years
≥4High10.4–12.3 per 100 patient-years

*The original study reported separate incidence rates: score 0, 1.9; 1, 2.5; 2, 5.3; 3, 8.4; 4, 10.4; and ≥5, 12.3 major bleeding events per 100 patient-years among warfarin-treated patients. Grouping these rates into low/moderate/high categories follows the published classification summary.

Clinical use and limitations

  • The original derivation cohort comprised 3,791 Medicare beneficiaries with atrial fibrillation; the reported c-statistic was 0.67 in warfarin-treated patients.
  • The score was developed in the warfarin era. Its absolute incidence estimates should not be directly transferred to an individual patient or assumed to represent risk with contemporary DOAC therapy.
  • The genetic component refers to CYP2C9 variants; routine genetic testing is not implied by this calculator. If status is unknown, do not assume the factor is absent when the clinical question requires a complete assessment.
  • The original report does not provide detailed operational thresholds for every broad criterion (for example, anemia, hepatic/renal disease, or excessive fall risk). Apply clinical definitions and documentation consistently.

References

Gage BF, Yan Y, Milligan PE, et al.Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillation (NRAF). Am Heart J. 2006;151(3):713–719. doi:10.1016/j.ahj.2005.04.017
https://doi.org/10.1016/j.ahj.2005.04.017
Sanders GD, Lowenstern A, Borre E, et al.Stroke Prevention in Patients With Atrial Fibrillation: A Systematic Review Update. AHRQ Comparative Effectiveness Review No. 214. 2018. Table 23 summarizes HEMORR₂HAGES factors and categories.
NCBI Bookshelf: NBK534143
2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation.J Am Coll Cardiol. 2024;83(1):109–279. doi:10.1016/j.jacc.2023.08.017. Recommends against using bleeding-risk scores in isolation to determine OAC eligibility; use them to identify and modify bleeding risk factors.
https://doi.org/10.1016/j.jacc.2023.08.017
Clinical disclaimer: This calculator is an educational clinical decision-support aid, not a diagnostic instrument or a substitute for individualized assessment. Bleeding-risk scores should not be used alone to decide whether to initiate, continue, or withhold oral anticoagulation. Assess thromboembolic risk, prior bleeding, modifiable bleeding factors, concomitant medications, renal/hepatic function, patient preferences, and the overall net clinical benefit. Follow current guidelines and local protocols.
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