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 Clinical Prediction Rule for Hemorrhages

        We recently developed a clinical prediction rule and acronym for major bleeding, HEMORR2HAGES (Table 1).  To develop this scheme, we combined bleeding risk factors from existing classification schemes into a new clinical prediction rule (Table 2). We scored HEMORR2HAGES by adding 2 points for a prior bleed and 1 point for each of the other risk factors (Table 2).  We quantified the risk of bleeding using Medicare data from 3791 Medicare beneficiaries with atrial fibrillation: 

Table 1. Incidence of Major Bleeds in National Registry of Atrial Fibrillation



N of Bleeds

Bleeds per 100 pt-yrs warfarin (95% CI)




1.9 (0.6-4.4)




2.5 (1.3-4.3)




5.3 (3.4-8.1)




8.4 (4.9-13.6)




10.4 (5.1-18.9)




12.3 (5.8-23.1)






N = number; pt-yrs = patient-years.
Adapted from Gage BF et al. Clinical classification schemes for predicting hemorrhage: Results from the National Registry of Atrial Fibrillation (NRAF). Am Heart J 2006;151:713-9.

Table 2. Independent bleeding-risk factors (and points)

HEMORR2HAGES Risk Factors (score)


Hepatic (1) or renal disease (1)

Hepatic disease: cirrhosis, two-fold or greater elevation of AST or APT, or albumin < 3.6 g/dL
Renal insufficiency:  Cr clearance < 30 ml/min

Ethanol use (1)

History of alcohol abuse, recent hospitalization for alcohol-related illness, and worsening liver disease

Malignancy (1)

Recent metastatic cancer

Older (age > 75) (1)

Calculated from birth date

Reduced platelet count (1) or function (1)

Platelets < 75,000
Schedule use of antiplatelet therapy (e.g. daily aspirin) or NSAID therapy; or blood dyscrasia

Re-Bleeding (2)

Prior hospitalization bleeding

Hypertension, uncontrolled (1)

Blood pressure not currently in control: most recent systolic bp > 160 torr

Anemia (1)

Most recent hematocrit < 30 or hemoglobin < 10 g/dL

Genetic factors (1)

CYP2C9*2 and/or CYP2C9*3

Elevated risk of fall including neuropsychiatric disease (1)

Alzheimer's dementia, Parkinson's disease, schizophrenia, or any condition predisposing to repeated falls

Stroke (1)

Prior ischemic stroke or brain infarct detected by brain imaging

Cr = creatinine; AST = aspartate transaminase (also called serum glutamic oxaloacetic);
ALT = aspartate transaminase (also called serum glutamate pyruvate transaminase); NSAID = Non steroidal anti-inflammatory drugs, excluding cyclooxygenase II-specific inhibitors; bp = blood pressure; CYP2C9*2 and/or CYP2C9*3 genotypes were not included in the original scheme.

Barnes-Jewish Hospital at Washington University Medical Center.

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Commercial use of this Web site and any part thereof, including the dosing algorithm contained herein, is prohibited without written authorization. Research on this page was supported by AHRQ (R01 HS10133). The Web site was supported by the Barnes-Jewish Hospital Foundation and a diagnostics company. If you would like to make a donation to support this non-profit site, click here.

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