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Correspondence |

Deep vs Lobar Intracerebral Hemorrhage on HAS-BLED Scoring System FREE TO VIEW

Birsen Ince, Prof Dr; Gulcin Benbir Senel, Assoc Prof Dr
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

CORRESPONDENCE TO: Gulcin Benbir Senel, Istanbul University, Cerrahpaşa Faculty of Medicine, Department of Neurology, 34098, Istanbul, Turkey


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;149(6):1589-1590. doi:10.1016/j.chest.2016.03.055
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Published online

We have read with great interest the article entitled “Recalibration of the HAS-BLED Score: Should Hemorrhagic Stroke Account for One or Two Points?” in a recent issue of CHEST (February 2016). The authors noted that after a hemorrhagic stroke, it is unclear whether it should count 1 point (either for stroke or bleeding) or 2 points (1 point each for stroke and bleeding) on the bleeding risk score HAS-BLED (hypertension, abnormal renal/liver function [1 or 2 points], stroke, bleeding history or predisposition, labile international normalized ratio, elderly [> 65 years], drugs/alcohol concomitantly [1 or 2 points]). About 2 years ago, we emphasized this issue, in addition to other criteria used in HAS-BLED scoring, in our article entitled “Should HAS-BLED scoring be revised for better risk estimation in patients with intracerebral hemorrhage?” In this article, we suggested that the type of stroke should be evaluated separately (as ischemic or hemorrhagic) for a better evaluation and estimation of recurrent intracerebral hemorrhage. In the study of Nielsen et al, recalibration of the HAS-BLED score (counting 2 points for a hemorrhagic stroke) resulted in improved accuracy of predicting major bleeding events, which supports our article and suggestions. Such an approach would result in a more accurate assessment of bleeding risk in patients with atrial fibrillation.

The other suggestion of ours mentioned by Nielsen et al was that hemorrhagic stroke may be further grouped as deep vs lobar in location, which has not yet been studied. We have suggested that hemorrhagic stroke and lobar intracerebral hemorrhage should be scored differently. We propose this approach because oral anticoagulation therapy would result in about 31 fewer thromboembolic strokes per 1000 patients with lobar hemorrhages, at a cost of 150 additional intracerebral hemorrhages in patients with atrial fibrillation. For 1000 patients with deep hemorrhages, however, oral anticoagulation therapy would result in about 31 fewer thromboembolic strokes but at a cost of 19 additional intracerebral hemorrhages during the first year of treatment. Because lobar hemorrhages are mostly associated with cerebral amyloid angiopathy, the safety of acetylsalicylic acid is even being discussed as secondary prophylaxis for these patients. Further studies in patients with atrial fibrillation using HAS-BLED scoring in this context—scoring 1 or 2 points for deep vs lobar hemorrhages in addition to scoring 1 point each for stroke and bleeding separately in hemorrhagic strokes—would also provide a better comprehension of the necessity for revising the HAS-BLED scoring system and offer a better risk estimation in these patients.

References

Nielsen P.B. .Larsen T.B. .Lip G.Y. . Recalibration of the HAS-BLED score: should hemorrhagic stroke account for one or two points? Chest. 2016;149:311-314 [PubMed]journal. [CrossRef] [PubMed]
 
Ince B. .Benbir G. .Gozubatik-Celik G. . Should HAS-BLED scoring be revised for better risk estimation in patients with intracerebral hemorrhage? Expert Rev Cardiovasc Ther. 2014;12:929-931 [PubMed]journal. [CrossRef] [PubMed]
 
Eckman M.H. .Rosand J. .Knudsen K.A. .et al Can patients be anticoagulated after intracerebral hemorrhage? A decision analysis. Stroke. 2003;34:1710-1716 [PubMed]journal. [CrossRef] [PubMed]
 
Selim M.H. .Molina C.A. . Elderly and forgetful. Is aspirin safe for you? Stroke. 2014;45:3153-3154 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Tables

References

Nielsen P.B. .Larsen T.B. .Lip G.Y. . Recalibration of the HAS-BLED score: should hemorrhagic stroke account for one or two points? Chest. 2016;149:311-314 [PubMed]journal. [CrossRef] [PubMed]
 
Ince B. .Benbir G. .Gozubatik-Celik G. . Should HAS-BLED scoring be revised for better risk estimation in patients with intracerebral hemorrhage? Expert Rev Cardiovasc Ther. 2014;12:929-931 [PubMed]journal. [CrossRef] [PubMed]
 
Eckman M.H. .Rosand J. .Knudsen K.A. .et al Can patients be anticoagulated after intracerebral hemorrhage? A decision analysis. Stroke. 2003;34:1710-1716 [PubMed]journal. [CrossRef] [PubMed]
 
Selim M.H. .Molina C.A. . Elderly and forgetful. Is aspirin safe for you? Stroke. 2014;45:3153-3154 [PubMed]journal. [CrossRef] [PubMed]
 
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