HASBLED Does Not Justify Withholding OAC — EECC MCQ

Correct answer: B — No — high HASBLED score identifies patients requiring closer monitoring and modifiable bleeding risk factor correction, but does NOT justify withholding anticoagulation; the stroke risk from unmanaged AF almost always exceeds the bleeding risk, even at high HASBLED scores

Explanation lettering: D = shown as A · A = shown as B · E = shown as C · C = shown as D · B = shown as E

The HASBLED score assesses bleeding risk but was NEVER intended to withhold anticoagulation. The 2024 ESC AF Guidelines emphasise: (1) HASBLED identifies modifiable bleeding risk factors that should be addressed: uncontrolled HTN (H), abnormal renal/liver function (A), drugs (NSAIDs, antiplatelet — S), labile INR (B), elderly (E), excess alcohol (D); (2) at any given CHA₂DS₂-VA score, the NET CLINICAL BENEFIT of OAC almost always favours anticoagulation — because: (a) ischaemic stroke from AF is typically large, disabling, and often fatal (30-day mortality ~20%); (b) major bleeding on DOAC is often GI (treatable, lower mortality); (c) intracranial haemorrhage on DOACs is 50% less frequent than on warfarin; (3) aspirin is NOT an alternative (no meaningful AF stroke prevention, still causes significant bleeding); (4) if bleeding risk is truly prohibitive: LAAO may be considered (Class IIb).

Reference: ESC (2024): AF Guidelines