ATRIA Bleeding Risk Score
The ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) Bleeding Risk Score is a clinical tool designed to estimate the risk of major bleeding in patients with atrial fibrillation (AF) undergoing anticoagulation therapy, particularly with warfarin. Developed from the ATRIA study cohort, this score aids clinicians in estimating the risk of bleeding complications due to anticoagulants.
Components of the ATRIA Score
The ATRIA score assigns points based on five clinical factors:
- Anemia: Hemoglobin <13 g/dL in men or <12 g/dL in women (3 points)
- Severe Renal Disease: Estimated glomerular filtration rate (eGFR) <30 mL/min or dialysis-dependent (3 points)
- Age ≥75 years: (2 points)
- Prior Bleeding: History of any prior bleeding (1 point)
- Hypertension: History of hypertension (1 point)
| Score | 1-year risk of bleeding | |
|---|---|---|
| Low risk | 0-3 | 0.8% |
| Intermediate risk | 4 | 2.6% |
| High risk | 5 or more | 5.8% |
Comparison with other bleeding risk models
Several bleeding risk assessment tools exist for patients with AF, including HAS-BLED, HEMORR2HAGES, and ORBIT scores. Each incorporates various clinical parameters to stratify bleeding risk.
- HAS-BLED: Incorporates factors such as hypertension, abnormal renal/liver function, stroke history, bleeding history, labile INR, age >65, and concomitant drug/alcohol use. Some studies suggest HAS-BLED has comparable or slightly superior predictive capability for major bleeding compared to ATRIA.
- ORBIT: Includes factors like older age, reduced hemoglobin/hematocrit, bleeding history, insufficient kidney function, and treatment with antiplatelet agents. Research indicates that the ORBIT score may offer better discrimination and calibration for major bleeding events compared to both HAS-BLED and ATRIA.
Note that while these prediction models provide guidance, their accuracies are moderate. Clinical judgment should always complement risk scores, considering individual patient characteristics and preferences when making therapeutic decisions.
References
1. Fang MC, Go AS, Chang Y, et al. A new risk scheme to predict warfarin-associated hemorrhage: the ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) study. J Am Coll Cardiol. 2011;58(4):395-401. doi:10.1016/j.jacc.2011.03.031.
2. Proietti M, Raparelli V, Olshansky B, Lane DA, Lip GYH. Comparison of bleeding risk scores in patients with atrial fibrillation: insights from the AFFIRM trial. J Intern Med. 2018;283(1):49-61. doi:10.1111/joim.12692.
3. Senoo K, Proietti M, Lane DA, Lip GYH. Evaluation of the HAS-BLED, ATRIA, and ORBIT bleeding risk scores in atrial fibrillation patients on warfarin. Am J Med. 2016;129(6):600-607. doi:10.1016/j.amjmed.2015.11.027.
4. Olesen JB, Lip GY, Hansen ML, et al. Bleeding risk in ‘real world’ patients with atrial fibrillation: comparison of two established bleeding prediction schemes in a nationwide cohort. J Thromb Haemost. 2011;9(8):1460-1467. doi:10.1111/j.1538-7836.2011.04378.x.
5. Apostolakis S, Lane DA, Guo Y, Buller H, Lip GY. Performance of the HEMORR2HAGES, ATRIA, and HAS-BLED bleeding risk-prediction scores in patients with atrial fibrillation undergoing anticoagulation: the AMADEUS study. J Am Coll Cardiol. 2012;60(9):861-867. doi:10.1016/j.jacc.2012.06.019.
6. Lip GYH, Banerjee A, Boriani G, et al. Antithrombotic therapy for atrial fibrillation: CHEST guideline and expert panel report. Chest. 2018;154(5):1121-1201. doi:10.1016/j.chest.2018.07.040.
7. Friberg L, Rosenqvist M, Lip GY. Evaluation of risk stratification schemes for ischaemic stroke and bleeding in 182 678 patients with atrial fibrillation: the Swedish Atrial Fibrillation cohort study. Eur Heart J. 2012;33(12):1500-1510. doi:10.1093/eurheartj/ehr488.
8. Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest. 2010;138(5):1093-1100. doi:10.1378/chest.10-0134.
9. García-Fernández A, Roldán V, Lip GY, Marín F. Predicting bleeding risk in patients with atrial fibrillation: comparison of the HAS-BLED and ABC-Bleeding risk scores. J Am Coll Cardiol. 2017;70(2):138-139. doi:10.1016/j.jacc.2017.05.029.
10. Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2021;42(5):373-498. doi:10.1093/eurheartj/ehaa612.