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HEMORR₂HAGES Bleeding Risk Score

HEMORR₂HAGES estimates bleeding risk on warfarin in elderly AF patients (0–12): 2 points for prior bleed, 1 for each other factor. Bleeds per 100 patient-years: 1.9 (0), 2.5 (1), 5.3 (2), 8.4 (3), 10.4 (4), 12.3 (≥5).

  • Age (years)
  • Hepatic or renal disease (yes/no, +1)
  • Ethanol abuse (yes/no, +1)
  • Malignancy (yes/no, +1)
  • Reduced platelet count or function (incl. aspirin) (yes/no, +1)
  • Prior bleed (yes/no, +2)
  • Uncontrolled hypertension (yes/no, +1)
  • Anemia (yes/no, +1)
  • Genetic factors (CYP2C9 variant) (yes/no, +1)
  • Excessive fall risk (incl. neuropsychiatric disease) (yes/no, +1)
  • Prior stroke (yes/no, +1)
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Interpretation

ResultMeaning
0–1Low (1.9–2.5 bleeds/100 pt-yr)
2–3Intermediate (5.3–8.4)
≥ 4High (10.4–12.3)

Formula

H: hepatic or renal disease 1 · E: ethanol abuse 1 · M: malignancy 1 · O: older (age >75) 1 · R: reduced platelet count/function 1 · R₂: rebleeding (prior bleed) 2 · H: uncontrolled hypertension 1 · A: anemia 1 · G: genetic factors (CYP2C9) 1 · E: excessive fall risk 1 · S: stroke 1 (max 12)

Clinical pearls

  • Derived in Medicare beneficiaries (NRAF), so it is best suited to older AF patients.
  • Genetic (CYP2C9) status is rarely known; scoring it 0 when unknown underestimates risk slightly.
  • Age counts only if strictly over 75.

Examples

hemorr2hages 78 yo prior gi bleed, uncontrolled htnhemorrhages score 70F with cancer on aspirin and anemiahemorr2hages for 82 year old with frequent falls and prior stroke

FAQ

What does HEMORR₂HAGES stand for?

Hepatic/renal disease, Ethanol abuse, Malignancy, Older age, Reduced platelets, Rebleeding (2 points), Hypertension, Anemia, Genetic factors, Excessive fall risk, Stroke.

What is a high HEMORR₂HAGES score?

4 or more, corresponding to more than 10 bleeds per 100 patient-years on warfarin in the derivation cohort.

Evidence

  1. 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.

Cardiology · Reviewed 2026-10-14 · Methodology