HEMORR2HAGES score calculator

The point table

HEMORR2HAGES score, as printed in Oliveira and colleagues 2018, Table 1 (Oliveira 2018), with the same points in Pastori and colleagues 2019, Table 1B (Pastori 2019) (Gage 2006):

• Hepatic or renal disease: 1
• Ethanol (alcohol) abuse: 1
• Malignancy: 1
• Older age (75 or older): 1
• Reduced platelet count or function: 1
• Rebleeding risk (history of bleeding): 2
• Hypertension (uncontrolled): 1
• Anemia: 1
• Genetic factors (CYP2C9 variants): 1
• Excessive fall risk or neuropsychiatric disease: 1
• Stroke or TIA: 1

The maximum is 12. Each letter of the name stands for one item, in the order above; "R2" is rebleeding, the only item worth 2 points.

Oliveira and colleagues print these definitions for their study: hepatic disease as serum albumin under 3.3 g/dL or hepatic failure; renal disease as serum creatinine over 2.3 mg/dL or kidney failure; ethanol abuse as more than 20 units of alcohol a week; uncontrolled hypertension as systolic blood pressure over 160 mmHg; and anemia as hemoglobin under 12 g/dL in women and under 13 g/dL in men (Oliveira 2018).

Worked example: a 78-year-old (1) with a past bleed (2) and anemia (1), and none of the other factors, scores 4, the high group.

Risk groups

Oliveira and colleagues print the groups as low (0 to 1 point), intermediate (2 to 3) and high (4 or more) (Oliveira 2018). Sen and colleagues print the same three groups (Sen 2025). Neither open text prints a bleeding rate for each score, so this page does not give one.

A past bleed alone (2 points) already places someone in the intermediate group.

Reading the result

In 4,824 Chinese inpatients with AFib, Guo and colleagues report a C statistic of 0.69 (95% CI 0.62 to 0.77) for HEMORR2HAGES for major bleeding and 0.73 (0.61 to 0.85) for intracranial hemorrhage, against 0.72 and 0.83 for HAS-BLED. For major bleeding, the difference from HAS-BLED was not statistically significant (p = 0.258) (Guo 2016). In 280 Brazilian outpatients with heart disease on warfarin, Oliveira and colleagues found an AUC of 0.622 (95% CI 0.464 to 0.780) for major bleeding (Oliveira 2018).

The 2023 US atrial fibrillation guideline says that in people at high risk of stroke, bleeding risk scores should not be used on their own to decide whether to take an anticoagulant, but to find and change bleeding risk factors and to inform the decision (ACC/AHA 2023). General safety advice (not part of the score): never stop, skip or change a blood thinner because of a score. Talk to the clinician who prescribes it.

Related tools

For other bleeding scores in AFib, see the HAS-BLED score, the ORBIT bleeding score and, for people on warfarin, the ATRIA bleeding score; for stroke risk with AFib, CHA2DS2-VASc explained. To estimate kidney function, use the creatinine clearance calculator. For falls, see the Morse fall scale. Other bedside scores are listed under For healthcare professionals.