• Atrial Fibrillation, Bleeding Risks & Treatment Options


    If you have been diagnosed with atrial fibrillation (Afib or AF), then you have probably discussed various treatment options with your healthcare team. In addition to heart-healthy lifestyle changes, your team has probably recommended medications that stabilize your heart rate and heart rhythm as well as anticoagulant medications  that help to prevent blood clots that can cause stroke. You can learn more about both types of medications here.

    Like all medications, anticoagulants have benefits and risks. One of the more serious risks associated with taking anticoagulant medications is internal bleeding. While warfarin (Coumadin) and dabigatran (Pradaxa) have antidotes than can reverse their blood-thinning effects, the other anticoagulants medications do not.

    Your healthcare team will take the benefits and risks of the different medications into consideration when recommending medications and other treatment options for you. They will also factor in your age and overall physical health, the type of Afib you have, your other risk factors and your personal goals – in other words, how you prefer to live your life.

    Your risk for internal bleeding is an especially serious issue that your doctor will evaluate. Fortunately, a number of tools have been developed to help doctors evaluate a person’s individual risk for internal bleeding. Doctors can use the data obtained from these tools to develop the best treatment recommendations for you.

    Let’s review the most commonly used evaluation tools.

    Tools for Evaluating the Risks and Benefits of Anticoagulation

    Your healthcare team may use one or more of the following tools to help make the best treatment recommendations for you. This is why it is absolutely critical that you answer all of your doctor’s questions honestly and completely. The information you provide is essential for developing a total picture of your overall health.


    The CHADS2 scoring system is a simple tool that is effective for estimating stroke risk. This instrument takes into consideration the presence (or absence) of the following health issues:

    Congestive heart failure

    High blood pressure (Hypertension)

    Age (the risk is higher if you are 75 years or older)


    S2troke (the number 2 means the doctor will score your risk higher if you have had a previous stroke)


    CHA2DS2-VASc is the short name for a scoring system doctors use to evaluate an individual’s risk for stroke due to Afib. Each part of the acronym stands for a health condition that your doctor will take into consideration. The numbers indicate the relative importance of the different conditions. CHA2DS2-VASc stands for:

    Congestive heart failure

    High blood pressure (Hypertension)

    A2ge (the risk is higher if you are 75 years or older)


    S2troke (the number 2 means the doctor will score your risk higher if you have had a previous stroke)

    Vascular disease

    Age (if you are 65-74 years old)

    Sex category

    If your overall CHA2DS2-VASc score is high, then you will likely benefit from anticoagulant therapy. If your overall CHA2DS2-VASc score is low, then your risk for bleeding may be higher than your risk for stroke, so you will not be treated with blood-thinning medication.


    Another scoring system that your doctor may use to evaluate your risk for internal bleeding is called HAS-BLED. Each initial in HAS-BLED stands for an aspect of your overall condition. HAS-BLED stands for:

    High blood pressure (Hypertension)

    Abnormal kidney and/or liver function

    Stroke in your medical history


    Labile INRs (INR stands for International Normalized Ratio. An INR test is used to measure the blood-thinning effect of warfarin. A labile INR is a test result showing that the blood is not clotting in a predictable manner.)

    AgE (whether you are older or younger than 65 years of age)

    Drugs or alcohol (whether you take drugs or drink alcohol influence your risk)

    Your doctor will use all of this information to calculate a final score that provides guidance on the best treatment method for your Afib.


    Another assessment tool for bleeding risk is HEMORR2HAGES, which stands for:

    Hepatic (liver) or kidney disease

    Ethanol (alcohol) abuse

    Malignancy history

    Older (age 75 or older)

    Reduced platelet count or function (this can mean a number of things, including use of aspirin or anything else that might already interfere with the blood’s ability to clot)

    Rebleeding Risk2 (a history of bleeding problems in the past; in this case, the number 2 is a score the physician will add depending on your risk factor)

    High blood pressure (uncontrolled)

    Anemia (a deficiency of red blood cells)

    Genetic factors

    Excessive fall risk (whether you are prone to loss of balance and falling, which can lead to injuries such as cuts and bruising

    Stroke history

    As with the other risk-evaluation instruments, your doctor will calculate a score based on all of these factors and then will use the score to help develop the best treatment plan for you.

    ATRIA Bleeding Risk Score

    ATRIA this is short for AnTicoagulation and Risk Factors In Atrial Fibrillation. As with the other instruments for scoring bleeding risk, your doctor will take various details about your health and medical history into consideration when developing a treatment plan for you. These points include the following:


    Severe kidney disease

    Age (age 75 or up is a higher risk)

    Any prior bleeding problems, such as gastrointestinal bleeding

    High blood pressure (Hypertension)

    Treatment Options

    While atrial fibrillation can be frightening, especially when you are having symptoms, there are a number of treatment options are available. These include the medications discussed above that may be used to stabilize your heart rate and heart rhythm and to help prevent blood clots that can cause stroke.

    Some people with Afib are unable to take these medications and need to explore other treatment options. If medications aren’t working for you, your doctor may recommend a procedure such as electrical cardioversion, catheter ablation or surgical maze to help restore your heart to normal rhythm. You can learn more about these treatments here.

    If anticoagulant medications are not working for you and your Afib cannot be eliminated or adequately controlled, then your healthcare team may focus on options that reduce your risk for stroke. Left atrial appendage (LAA) closure (also known as LAAC or LAA closure) is a procedure that seals off the area of the heart called the left atrial appendage (LAA) so that blood clots cannot form in it. There are different LAAC techniques, including sewing the LAA sac closed with a tool or implanting a tiny device in the opening of the LAA.

    You can learn more about LAA closure techniques in the SecondsCount Left Atrial Appendage Closure Center.