I've always had concerns about the CHADS matrix and now I've looked more closely at HASBLED.
This is designed to assess one's risk of bleeding but nowhere does it refer to INR except to add just 1 point if your INR is labile (ie not stable). By definition therefore, if you don't take anticoagulants (same as an INR outside therapeutic range) only 1 point separates you from another who is properly anti-coagulated and consistently in therapeutic range. Hardly worth bothering according to this.
But statistically, it most certainly is worth being anticoagulated. Unprotected, the youngest and otherwise healthiest AF sufferer is 5 times more likely to have a stroke than someone with a similar profile in the general population who does not have the condition. If you're not young or healthy then it can be much higher.
The seriously misleading CHADS matrix tells us to wait for a first stroke before we take anticoagulation seriously and the equally misleading HASBLED tells us that the benefit of taking anticoagulants is only very marginal. Furthermore, HASBLED takes no account of the fact that bleed risk only significantly increases at an INR level well above therapeutic range. Stroke risk, on the other hand, significantly increases immediately below therapeutic range. There is not a clear balance between the two and the tipping point for bleed is unlikely to be reached by someone with well managed anti-coagulation. The tipping point for stroke however is ever-present unless properly anticoagulated.
The sooner the AF community wakes up, pops brain in gear and discards these utterly discredited matrices, the better.
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AnticoagulateNow
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My EP never took any notice of my CHADS score of 1 and anticoagulated anyway. He just said we don't want you having a stroke in the run up to your ablation and prescribed Apixaban. In fact he was surprised to find out my GP had done nothing whatsoever about any anticoagulant on my behalf and was even reluctant to prescribe the one my EP told them to...I had fight for it.
Similar to Loo here. I have a score of zero but fairly severe arrhythmia, it's a non-brainer for me to be anti-coagulated but according to CHADS I needn't be. My EP put me on AG's a few years ago and I'm certainly glad he didn't wait for me to get my score up before making that decision !!! It is only a guide, but have to say I think it's a bad one.
I know that you are even more pro anticoagulation even than I am but I think you should not be so quick to rubbish a system which however flawed is still saving lives. Chads2 is I agree a very flawed system but surely most EPs and people who actually know now use the CHADS2VASC system anyway. The HASBLED does have its uses on occasions but needs understanding and using with care. I'm not sure that I agree with NICE in their recent PDA giving so much credence to Hasbled BUT recent events in USA with blood sucking ambulance chasers encouraging people to sue drug companies over NOACs when a patient has either died or been critically ill as a result of gastro-intestinal bleeds, make it essential for patients to be given all the information available and encouraged to make their own mind up. This if only to protect the doctors and drugs companies.
Thanks Bob, I misuse the abbreviated term CHADS to include all its variations. I understand your comment about the ambulance chasers and the legal ramifications of not providing sufficient information to patients. I'm all for that but my point is that both CHADS and Hasbled are misleading. For example, if a CHADS score of 0 meant that there was no enhanced risk of stroke whatsoever, for the AF sufferer, then it would have value. Depending on our score, we could all make an informed choice. But that is not what a CHADS score of 0 means and this is where it is awfully misleading. And for many patients that misdirection is reinforced when told by the medical practitioner "Your score is 0 (or 1) so you don't need anti-coagulation." There may be all sorts of valid reasons why a patient shouldn't be taking warfarin but a CHADS score of 0 or 1 is most certainly not one of them! Now, that is probably what the ambulance chasers should be concentrating on - "I'm sorry for your loss Mrs Brown - your husband was told he didn't need anticoagulation, is that correct?"
With regards to Hasbled, I'm not dismissing the risk of bleed. But my point here is that it is over-egged and many patients are left with a distorted summary; that the fear of bleed surpasses the fear of stroke. For the huge majority of patients, it simply doesn't. But you're right, doctors mustn't go too far the other way and suggest there is no risk. I just want to see a fair and balanced assessment and I'm afraid the current matrices, while they may have some utility for medical professionals, provide only a distorted picture for patients.
INR is in the picture Rosy though it doesn't dominate the foreground as it should. It's one of the criteria which is assessed, though not by INR number but by whether or not it is stable. However, you've actually reinforced my point. Hasbled is used to help decide on whether or not one should take anti-coagulation but the risk of bleed, which is surely what is being considered in making that decision, significantly increases with a rising INR (a statement of the blindingly obvious of course) and, as we both agree, this is barely considered.
You are correct of course that as INR rises out of range there is a greater risk of bleeding- which is why we are campaigning like mad in our CCG for better monitoring of patients on Warfarin- however, in the context of deciding whether to offer OACs- this is before one reaches that point and is to help patients work out which is the higher risk.
One cardiologist locally told us the tricky bit is when the ChadsVasc and Hasbled score are both equal - it is easier to be sure about anti-coagulation when figures are higher for chadsvasc
All treatment has to be personalised and I think NICE have done a good job in trying to help patients make decisions,
One objection I have raised to those involved with NICE is that the risk of stroke is only given over a year but of course that is EVERY year- the response was that they can only give guidance based on evidence - so it is harder for them than we think but we can make our own judgement when deciding what to do,
As someone who has looked after stroke patients in my youth (!1) I insisted on Warfarin as soon as I was diagnosed so for me it's a no-brainer, but I appreciate others need to decide based on their own case/history/family history etc
Thanks for this post and so glad I read your bit rosyG, some of you may know I had a second opinion from an EP in sydney, who thought that my age precluded me from an ablation and gave me an alternative to Amiodarone (now 50mgs) to that of Flecainide and did recommend an anticoagulant.
Since then have seen my local Cardiologist who wasn't keen on changing my medication but did recommend I lower the dose from 100mgs to 50mgs of Amiodarone, which I am currently on.
The problem has now arisen from my local GP who did not see the need for any anticoagulant, even though my CHADS2 score is 1, and CHADSVASC score is 3. I am not familiar with the guidelines but this is what it says on the latest report, it has never even been mentioned before by anyone, so I asked for a test which could ascertain my blood thickness since I am on herbs for blood thinning along with asprin only to be told there was no such test available, now I am thinking of changing my GP to get all of this sorted out, as in effect no advise has been taken up from the EP that I visited recently.
Your thoughts on this would be appreciated and where I can get the information of Hasbled.
Ultramarine I want you to understand that I fully respect your views but please think very carefully about your decision to take herbs and aspirin to combat stroke risk.
INR testing is specific for warfarin. It is also not an exact science as any body who attended HRC last year will understand and there is still some doubt as to the range we should be aiming for anyway. Herbs or antiplatelets won't produce a results on any know blood test . The new oral anti-coagulants have no test for efficacy but are assumed to work because they do? There is no test as such for Hasbled OR Chards2vasc2, merely a set of values to work through and this can be discussed with you doctor should you wish to print off the data from the main website. I know that you are in Australia so maybe the latest thinking hasn't got to your country yet but providing AFA data can maybe help your quest.
Bob
Thankyou but this was not my view, there was no alternative available to me if you read my post.
Thanks beardy_chris I have checked out the site and my score is 2 It seems that this could be a test for me to ask for if they are not going to give me any anticoagulants.
I have a different issue with HASBLED. It assumes the patient is already on Warfarin as it refers to a labile INR. There is nothing that takes NOAC use into account. It is unhelpful in deciding whether or not to accept anticoagulation in the first place.
The problem with many of these tools is that they are too often seen as absolute determinants when in fact there are other individual factors which may have some weight in deciding treatment. My cardiologist told me that CHADS in all its forms does not apply to me as there are other reasons for me to be anticoagulated.
A valid point MrsPat. If one is intending to take an NOAC should anticoagulation be recommended, then I suppose that would be equivalent to a warfarin-taker having a consistently stable INR so you wouldn't score that extra point. Making a bleed less likely Hasbled, in such a case, would suggest towards anti-coagulation (notwithstanding other individual underlying factors) - but again, only marginally so.
Well, my CHADSVasc score is 1 (for being female) but I managed to persuade the doctor to put me on warfarin because my male cousin, who has AF too, had several TIAs at my age. The whole idea of waiting till you've had a stroke to say you're at risk of a stroke seems a bit rubbish to me! My GP also looked at my HAS-BLED score and I agree, they don't give enough credit for being properly anti-coagulated. But then to an expert, a difference of 1 really ought to be significant and perhaps that also needs explaining to patients...
As always sir, a thoughtful and thought provoking post, let's start with where I fully agree with you.
CHADS2VACS only scores us in AF makes some pretty wide assumptions about age and sex etc but for my mind takes no account whatsoever of any other underlying factors. So for example and purely my personal opinion, if one is male and 59 with no other contra-indications then you score zero, yet jump up to one on your birthday. It takes no account perhaps of weight, lifestyle smoking etc etc all of which we understand to be underlying stroke risk factors.
So here I understand and fully agree with you, I have actually challenged a few of the "top people" in the AF world on this and they say this is the current understanding and that other factors should not be taken into account, I must admit I personally disagree.
However and this is where perhaps we may take a different path,
It's what we have got
It's better than what we had before and certainly better then nothing.
Time will of course refine and make it better, and I am sure perhaps we shall be listened to.
Thank you Ian. I'm not entirely certain it's better than nothing when it is so misleading. With 'nothing', we tend to think more carefully about such things as weight, smoking lifestyle etc as you have wisely observed. Still, I'm sure you're right that time will refine it and make it better but in the meantime if just one message prevailed - a Chads score of 0 or 1 is not a reason, on its own, to avoid anti-coagulants - then we can all safely await those improved revisions.
just another thought- maybe the 'labile INR' in hasbled is for if stopping anti-coag is being considered because of bleeds ??- again another reason for our campaign to get more frequent testing of range
Don't think it comes into it when considering starting anti-coagulation as INR won't have risen at that point
That makes sense Rosy. But my point remains valid that a significant factor in bleed risk must be an unstable INR. If we maintain INR in therapeutic range (TR), the risk of bleed is very slim - certainly nothing like the risk of stroke if you slip out of the bottom end of TR. And yet Hasbled only gives this factor 1 point.
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A Big Blind Spot in Anticoagulation Guidelines
Yes....but 5 times greater than what exactly?
Anti-coag query please 
Effectiveness of Warfarin
