Hypertension and hypercholesterolemia are predictive factors associated with type 2 diabetes persistence after metabolic surgery: A prospective study.

BACKGROUND: Metabolic surgery is the most effective therapeutic strategy for the management of type 2 diabetes (T2DM). Several preoperative clinical factors have been associated with T2DM remission after metabolic surgery. However, other potential predictors remain unexplored. AIM: To assess the role of basal (pre-surgery) clinical and biochemical parameters in T2DM remission after metabolic surgery. METHODS: A prospective study including 98 patients with T2DM undergoing metabolic surgery was performed. Clinical, anthropometric, and biochemical data were collected at baseline and 1 year following metabolic surgery. RESULTS: Patients without T2DM remission 1 year after metabolic surgery presented a longer duration of diabetes and higher glycated hemoglobin (HbA1c) levels; a higher percentage of these subjects were using insulin therapy, antihypertensive drugs, and lipid-lowering therapies before metabolic surgery, compared to those patients with T2DM remission. A lower percentage of T2DM remission after metabolic surgery was observed among patients with hypertension/hypercholesterolemia before surgery, compared to those patients without hypertension/hypercholesterolemia (51.7 % vs 86.8 %, p < 0.001, and 38.5 % vs 75 %, p < 0.001, respectively), and among patients with longer duration of diabetes (≥5 years vs <5 years; 44.4 % vs 83 %, respectively; p < 0.001). In the logistic regression model, diabetes duration, basal HbA1c, and the presence of hypertension and hypercholesterolemia before surgery were inversely related to T2DM remission following metabolic surgery, after adjusting for sex, age, waist circumference, and type of surgery. CONCLUSIONS: In a cohort of patients with obesity and T2DM, preoperative hypertension and hypercholesterolemia, together with a longer diabetes duration and higher HbA1c concentrations, were independent predictors of T2DM persistence after metabolic surgery.

Anxiety, trauma and well-being in health-care professionals during COVID-19 first wave in Spain: the moderating role of personal protection equipment availability.

BACKGROUND: The effect of COVID-19 on Health-Care Professionals' mental health has received increased attention in the last year's literature. However, previous studies essentially evaluated psychopathological symptoms and not the presence of positive mental health. Therefore, the first objective of the present research is to evaluate health-care professionals' mental illness (i.e., anxiety and traumatic intensity) and positive mental health (i.e., well-being) using the Complete State Model of Health. Our second objective is to study the effect of Personal Protection Equipment availability on professionals' mental health. METHODS: Two-hundred and thirty-two health-care professionals working in Spain in the first line of COVID-19 patient care participated in the study. To measure anxiety, traumatic intensity and well-being participants completed the State Trait Anxiety Inventory, the Davidson Trauma Scale, and the Mental Health Continuum-Short Form. Pearson correlations were used to examine the relationships between all scales. In order to test the two continua model of mental health, we used parallel analysis and exploratory factor analysis. To analyze anxiety, traumatic intensity, and well-being differences between health-care professionals with and without Personal Protection Equipment availability we conducted different ANOVAS. To test our hypothesis regarding the moderating role of Personal Protection Equipment availability in the effect of mental illness on positive mental health, data were subjected to a hierarchical regression analysis. RESULTS: As in previous studies, health-care professionals showed high levels of anxiety and traumatic intensity. They also presented low levels of well-being indicators. According to our hypothesis, results of parallel analysis and exploratory factorial analysis indicated that the measures of mental illness and positive mental health loaded on separate but correlated factors. Finally, Personal Protection Equipment availability moderated the effects of state anxiety and traumatic intensity on professionals' well-being. CONCLUSIONS: Health-care professionals' mental illness and positive mental health reflect distinct continua, rather than the extreme ends of a single spectrum. Therefore, it is essential to measure both psychopathology and the presence of positive health to comprehensively evaluate professionals' mental health. Finally, our results indicated that Personal Protection Equipment availability is essential not only for professionals' physical health, but also for their mental health.

Effectiveness of mRNA COVID-19 vaccines in preventing SARS-CoV-2 infections and COVID-19 hospitalisations and deaths in elderly long-term care facility residents, Spain, weeks 53 2020 to 13 2021.

Residents in long-term care facilities (LTCF) experienced a large morbidity and mortality during the COVID-19 pandemic in Spain and were prioritised for early COVID-19 vaccination. We used the screening method and population-based data sources to obtain estimates of mRNA COVID-19 vaccine effectiveness for elderly LTCF residents. The estimates were 71% (95% CI: 56-82%), 88% (95% CI: 75-95%), and 97% (95% CI: 92-99%), against SARS-CoV-2 infections (symptomatic and asymptomatic), and COVID-19 hospitalisations and deaths, respectively.

Development and Validation of the COMPLES Score for Differentiating Between Tuberculous Effusions with Low Pleural pH or Glucose and Complicated Parapneumonic Effusions.

BACKGROUND: The frequency of "complicated" pleural effusions (CPE) (i.e., pleural fluid pH ≤ 7.2 and/or glucose ≤60 mg/dL) of tuberculous origin (CTPE) is not well reported. This study aims to quantify their prevalence, and develop a score to differentiate CTPE from complicated parapneumonic effusions (CPPE). METHODS: Retrospective analysis of databases from three Spanish hospitals which included patients with CTPE and CPPE. Forty percent of the study population served to generate a scoring system (COMPLES, COMplicated PLeural Effusion Score) that was further validated in the remaining 60 %. RESULTS: During the study period (1992-2015) 549 patients were diagnosed with tuberculous effusions and 434 parapneumonic effusions, of whom 25 and 64 %, respectively, had CPE. COMPLES was based on the combination of pleural fluid adenosine deaminase (ADA), the percentage of mononuclear cells (MNC %), pH, and age. The cutoff values and assigned scores were: ADA (<46 IU/L [0 points], 46-100 IU/L [4 points], ≥100 IU/L [6 points]), MNC % (<10 % [0 points], 10-50 [3 points], >50 [8 points]), pH (<7.07 [0 points], 7.07-7.20 [3 points], >7.20 [5 points]), and age (≥30 [0 points], <30 years [3 points]). A sum of 12 or more points had 97 % sensitivity, 92 % specificity, likelihood ratio positive 12.3, likelihood ratio negative 0.03, and area under the curve of 0.947 for identifying CTPE versus CPPE in the validation set. CONCLUSIONS: CPE is not an unusual presentation of tuberculosis. A simple new scoring system provides a reliable tool for differentiating between CTPE and CPPE.

Agonista del receptor de trombopoyetina como tratamiento de trombocitopenia asociada a lupus eritematoso sistémico / Thrombopoietin-receptor agonist as a treatment of thrombocytopenia associated with systemic lupus erythematosus

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sST2 levels are associated with all-cause mortality in anticoagulated patients with atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) is associated with high morbidity and mortality, even despite the use of oral anticoagulation (OAC). Soluble suppression of tumorigenicity-2 (sST2) is a member of the interleukin-1 receptor family [interleukin-1 receptor-like 1 (IL1RL1)], which has been associated with an increased risk of mortality and morbidity in heart failure or acute coronary syndrome. We assessed the predictive value of sST2 levels in an unselected 'real-world' cohort of anticoagulated AF patients. METHODS: We included 562 patients (49% male; median age 77 [IQR: 71-82]) with permanent AF who were stable (for at least 6 months) on OAC (INRs 2.0-3.0). sST2 levels were quantified by ELISA. Patients were followed-up for up to 4 years, and cardiovascular events and all-cause mortality were recorded. RESULTS: Median (IQR) of sST2 levels was 51.23 (39.09-67.40) µg/L. Median follow-up was 1587 days [IQR 1482-1617], and during this period, 91 patients died (16.2%, 3.72%/year). The c-statistic for predicting mortality with sST2 was 0.58 + 0.03; P = 0.017). On multivariate analysis, age [hazard ratio (HR) 1.09 (1.05-1.13); P < 0.001], diabetes mellitus [1.76 (1.08-2.88); P = 0.023], previous stroke [2.16 (1.29-3.60); P = 0.003] and sST2 levels [1.008 (1.002-1.14); P = 0.008] were independently associated with mortality. Concentrations of sST2 were also significantly associated with the risk of mortality, even after adjusting for the CHA2 DS2 -VASc score [HR: 1.007 (1.001-1.013); P = 0.014]. CONCLUSIONS: In an anticoagulated AF patient's cohort, sST2 levels are an independent predictive factor of all-cause mortality. sST2 levels could be a biomarker used to improve clinical risk assessment in anticoagulated AF patients.

Comparación de las ecuaciones de filtrado glomerular estimado para determinar la posología de los nuevos anticoagulantes orales para pacientes con fibrilación auricular / Comparison of estimated glomerular filtration rate equations for dosing new oral anticoagulants in patients with atrial fibrillation

Introducción y objetivos: Los nuevos anticoagulantes orales requieren ajuste de la posología según la función renal. El objetivo de este estudio es determinar la discrepancia existente entre la hipotética posología recomendada de estos fármacos empleando diferentes ecuaciones de filtrado glomerular estimado en pacientes con fibrilación auricular. Métodos: Análisis transversal de 910 pacientes con fibrilación auricular e indicación de anticoagulación oral. Se estimó el filtrado glomerular con las ecuaciones de Cockcroft-Gault, Modification of Diet in Renal Disease y Chronic Kidney Disease Epidemiology Collaboration. Para dabigatrán, rivaroxabán y apixabán, se identificaron discrepancias de la dosis cuando no coincidían con las dosis recomendadas según se usara una u otra ecuación. Resultados: En el conjunto de la población, respecto a la ecuación de Cockcroft-Gault, la discrepancia de la posología de dabigatrán fue del 11,4% con la ecuación Modification of Diet in Renal Disease y del 10 con la Chronic Kidney Disease Epidemiology Collaboration; las discrepancias de la posología de rivaroxabán fueron del 10% y el 8,5% respectivamente. La menor discrepancia se observó con apixabán: el 1,4% con la primera y el 1,5% con la segunda. En los pacientes con un valor según la ecuación de Cockcroft-Gault < 60 ml/min o en los pacientes ancianos, las discrepancias en las posologías de dabigatrán y rivaroxabán fueron superiores, entre el 13,2 y el 30,4%. La discrepancia en cuanto a la posología de apixabán se mantuvo en un valor < 5% en estos pacientes. Conclusiones: La discrepancia en las posologías de los nuevos anticoagulantes orales empleando ecuaciones distintas es frecuente, sobre todo en los pacientes ancianos con deterioro de la función renal. Esta discrepancia fue mayor para las posologías de dabigatrán y rivaroxabán que para la de apixabán. Se necesitan nuevos estudios para esclarecer la importancia clínica de estas discrepancias y determinar la posología óptima de los anticoagulantes según la ecuación que se use para estimar la función renal (AU)

Introduction and objectives: New oral anticoagulants require dosing adjustment according to renal function. We aimed to determine discordance in hypothetical recommended dosing of these drugs using different estimated glomerular filtration rate equations in patients with atrial fibrillation. Methods: Cross-sectional analysis of 910 patients with atrial fibrillation and an indication for oral anticoagulation. The glomerular filtration rate was estimated using the Cockcroft-Gault, Modification of Diet in Renal Disease and Chronic Kidney Disease Epidemiology Collaboration equations. For dabigatran, rivaroxaban, and apixaban we identified dose discordance when there was disagreement in the recommended dose based on different equations. One-hundred samples from 54 patients with virologic breakthrough during entecavir, lamivudine or adefovir treatment and 21 samples from 21 nucleoside-naïve patients were tested by direct sequencing and an updated line probe assay (Innogenetics, HBV DR v.3) which incorporates probes that can detect mutations at 11 positions of the reverse transcriptase region of the HBV polymerase gene. Results: Among the overall population, relative to Cockcroft-Gault, discordance in dabigatran dosage was 11.4% for Modification of Diet in Renal Disease and 10% for Chronic Kidney Disease Epidemiology Collaboration, discordance in rivaroxaban dosage was 10% for Modification of Diet in Renal Disease and 8.5% for the Chronic Kidney Disease Epidemiology Collaboration. The lowest discordance was observed for apixaban: 1.4% for Modification of Diet in Renal Disease and 1.5% for the Chronic Kidney Disease Epidemiology Collaboration. In patients with Cockcroft-Gault < 60 mL/min or elderly patients, discordances in dabigatran and rivaroxaban dosages were higher, ranging from 13.2% to 30.4%. Discordance in apixaban dosage remained < 5% in these patients. Conclusions: Discordance in new oral anticoagulation dosages using different equations is frequent, especially among elderly patients with renal impairment. This discordance was higher in dabigatran and rivaroxaban dosages than in apixaban dosages. Further studies are needed to clarify the clinical importance of these discordances and the optimal anticoagulant dosages depending on the use of different equations to estimate renal function (AU)

Comparison of estimated glomerular filtration rate equations for dosing new oral anticoagulants in patients with atrial fibrillation.

INTRODUCTION AND OBJECTIVES: New oral anticoagulants require dosing adjustment according to renal function. We aimed to determine discordance in hypothetical recommended dosing of these drugs using different estimated glomerular filtration rate equations in patients with atrial fibrillation. METHODS: Cross-sectional analysis of 910 patients with atrial fibrillation and an indication for oral anticoagulation. The glomerular filtration rate was estimated using the Cockcroft-Gault, Modification of Diet in Renal Disease and Chronic Kidney Disease Epidemiology Collaboration equations. For dabigatran, rivaroxaban, and apixaban we identified dose discordance when there was disagreement in the recommended dose based on different equations. RESULTS: Among the overall population, relative to Cockcroft-Gault, discordance in dabigatran dosage was 11.4% for Modification of Diet in Renal Disease and 10% for Chronic Kidney Disease Epidemiology Collaboration, discordance in rivaroxaban dosage was 10% for Modification of Diet in Renal Disease and 8.5% for the Chronic Kidney Disease Epidemiology Collaboration. The lowest discordance was observed for apixaban: 1.4% for Modification of Diet in Renal Disease and 1.5% for the Chronic Kidney Disease Epidemiology Collaboration. In patients with Cockcroft-Gault<60mL/min or elderly patients, discordances in dabigatran and rivaroxaban dosages were higher, ranging from 13.2% to 30.4%. Discordance in apixaban dosage remained<5% in these patients. CONCLUSIONS: Discordance in new oral anticoagulation dosages using different equations is frequent, especially among elderly patients with renal impairment. This discordance was higher in dabigatran and rivaroxaban dosages than in apixaban dosages. Further studies are needed to clarify the clinical importance of these discordances and the optimal anticoagulant dosages depending on the use of different equations to estimate renal function.

Safety of new oral anticoagulant drugs: a perspective.

The recent development of new oral anticoagulants (NOACs) offers the possibility of efficacy, relative safety and convenience compared with warfarin. This could lead to greater patient compliance, with easier management and improved provision of thromboprophylaxis. Safety whilst using NOACs should be focused on bleeding cases, surgery or on the management of patients receiving anticoagulant therapy with concomitant impairment of renal function, especially since many NOACs are dependent on renal excretion. Thus, if the clearance creatinine indicates severe renal impairment, NOACS will be contraindicated or their dose needs to be changed. In patients who need surgery, there are published protocols of management, depending on the severity of the intervention and renal function. In the case of severe hemorrhage, requiring rapid reversal of the anticoagulant effect and in the absence of specific antidotes, alternatives such as one of the nonspecific haemostatic agents must be considered. Clinical evaluation in bleeding situations and a meticulous risk-benefit appraisal for NOACs is needed, and these procoagulant agents and patients must be monitored closely. This article provides an overview of the pharmacology and potential risks, as well as the efficacy and safety of NOACs.

SAMe-TT2R2 score, time in therapeutic range, and outcomes in anticoagulated patients with atrial fibrillation.

BACKGROUND: Oral anticoagulation is highly effective in preventing stroke and mortality in nonvalvular atrial fibrillation patients. However, the efficacy and safety of vitamin K antagonists (the main oral anticoagulation drug used) strongly depends upon the quantity of anticoagulation control, as reflected by the average percentage of the time in therapeutic range of international normalized ratio 2.0-3.0. An easy, simple prediction of which atrial fibrillation patients are likely to do well on vitamin K antagonists (with good average time in therapeutic range) could guide decision-making between using vitamin K antagonists (eg, warfarin) and non-vitamin K antagonist oral anticoagulants. METHODS AND RESULTS: In a consecutive cohort of nonvalvular atrial fibrillation patients attending our anticoagulation clinic, we tested the hypothesis that the new Sex, Race, Medical history, Tobacco use, Race (SAMe-TT2R2) score was a predictor for good average time in therapeutic range, and second, this would translate into adverse events in a "real world" cohort of patients with nonvalvular atrial fibrillation. The incidence of bleeding, adverse cardiovascular events (including stroke/thromboembolism), and mortality during the follow-up was higher with increasing SAMe-TT2R2 score. The SAMe-TT2R2 score was predictive for the composite of all adverse events (hazard ratio 1.32 [95% Confidence Interval 1.17-1.50]; P <.001), adverse cardiovascular events (1.52 [1.28-1.83]; P <.001), and all-cause mortality (1.41 [1.16-1.67]; P = .001). A trend was also observed for major bleeding events (1.23 [0.99-1.53]; P = .059). CONCLUSION: In a "real world" cohort of consecutive patients with nonvalvular atrial fibrillation, a high SAMe-TT2R2 score (reflecting poor anticoagulation control with poor time in therapeutic range) was associated with more bleeding, adverse cardiovascular events, and mortality during follow-up.

Recent changes in school-based policies on physical activity and nutrition in Spain.

BACKGROUND: This study evaluates the changes in Spain between 2006 and 2012, of school-based policies encouraging healthy eating and the undertaking of physical activity (PA). METHODS: A longitudinal study was undertaken comprising 277 representative schools from all the regions of Spain. The questionnaires were completed by the school management board. An indicator for school policies on PA was constructed (score 0-4) from the following indicators: (i) participation in PA programmes, (ii) existence of written PA guidelines, (iii) training of teachers about PA and (iv) organization of extracurricular PA activities. For nutrition, indicators similar to the first three for PA were evaluated, together with access to healthy foods (score 0-4). In addition to comparing the scores for 2006 and 2012, multivariate linear regression was used to study the association between the characteristics of the schools and the changes in the scores. RESULTS: The indicators for school-based policies on nutrition and PA improved between 2006 and 2012: the average score for PA increased from 1.33 to 1.79 (P < 0.001) and that for nutrition from 1.28 to 1.92 (P < 0.001). The greatest changes were seen regarding the written guidelines for action and participation in PA and nutrition programmes as well as the training of teachers about nutrition. The schools with the least number of students had the highest changes in scores for policies on nutrition (P < 0.05). CONCLUSIONS: There has been an increase of school-based policies on PA and nutrition, although there is still room for improvement.

Dabigatran etexilate for venous thromboembolism: a safety evaluation.

INTRODUCTION: Recently, new oral anticoagulants (NOACs) have become available to treat thromboembolic disorders. The efficacy and safety of these agents have been thoroughly tested in various clinical trials. In this article, we discuss the evidence for the safety and efficacy of dabigatran in the prevention and treatment of venous thromboembolism (VTE). AREAS COVERED: We discuss the pharmacology of dabigatran and compare it to that of warfarin and two of the other popular NOACs, rivaroxaban and apixaban. The indications for and evidence behind dabigatran in the prevention of VTE are presented, as well as the trials examining its potential use for the treatment and extended treatment of VTE. We conclude by considering the safety aspects of the drug. EXPERT OPINION: For most patients the overall net clinical benefit would seem to be in favour of dabigatran. Both efficacy and safety have been proven in the setting of robust randomised controlled trials. 'Real world' registry data as well as long-term trial follow-up will add further critical information. Long-term experience might be one of the few advantages warfarin still has over dabigatran in patients who are eligible for both.

Circulating microparticles: challenges and perspectives of flow cytometric assessment.

Circulating blood microparticles are likely to play a significant role as messengers of biological information. Their accurate quantification and characterisation is challenging and needs to be carefully designed with preferable usage of fresh minimally-processed blood samples. Utilisation of flow cytometers specifically designed for analysis of small-size particles is likely to provide considerable methodological advantages and should be the preferable option. This viewpoint manuscript provides a critical summary of the key methodological aspects of microparticle analysis.

Novel oral anticoagulants in cardiovascular disease.

Nonvalvular atrial fibrillation (AF) confers an increased risk of thromboembolism, with a 5-fold higher risk of ischemic stroke. Oral anticoagulation (OAC) has shown to be highly effective in preventing stroke and mortality compared to placebo and is also used in patients without AF for both treatment and prophylaxis of venous thromboembolism. The OAC halts the coagulation by different mechanisms. Until recently, the only option was the vitamin K antagonists (VKAs), but their inherent limitations have promoted the development of novel oral anticoagulants (NOACs), which may offer efficacious and safer alternatives. Patients should be carefully selected to receive the most suitable treatment for each one. As the VKA efficacy and safety largely rely on the time the patient remains within the therapeutic range, this could be a useful selection criterion. Bleeding remains the main complication of all OACs. Although clinical trials of stroke prevention in AF have shown a significant reduction in hemorrhagic stroke and intracranial bleeding with the NOACs, as prescriptions are increasing, clinicians need to be prepared to accurate management of bleeding complications. Withholding the drug is usually enough for most cases of mild bleeding, but in patients with major, life-threatening bleeding, other measures, such as fluid replacement and blood transfusion, might be necessary while waiting for specific reversal agents that may reach the market soon. In case of acute bleeding, the accurate estimation of anticoagulant effect could also be needed, but the currently available coagulation tests only offer a qualitative measure. While awaiting long-term safety data, the choice between all these available therapies should be based on patient preferences, compliance, and ease of administration as well as on local factors affecting cost-effectiveness. But the increasing variety of therapeutic options when chronic OAC is needed can only improve the provided health care.

Common Questions in Anticoagulation Management in Atrial Fibrillation.

The limitations of the vitamin K antagonists (VKAs) have promoted the development of novel oral anticoagulants (NOACs) to benefit patients with poor predicted anticoagulation control. To assess the probability of good or poor anticoagulation control with VKAs, the SAMe-TT2R2 score has been developed. Trials of stroke prevention have shown a significant reduction in hemorrhagic stroke and intracranial bleeding with the NOACs. Clinicians need to be prepared to manage bleeding complications and patients requiring urgent surgery, systemic thrombolysis for ischemic stroke, or ST elevation myocardial infarction. This article addresses some of these management issues.

Cessation of oral anticoagulation in relation to mortality and the risk of thrombotic events in patients with atrial fibrillation.

Bleeding risk (often perceived, rather than actual) is a common reason for cessation of oral anticoagulation with Vitamin K antagonists (VKA). We investigate clinical outcomes in a consecutive population of VKA naïve atrial fibrillation (AF) patients, who initiated VKA therapy in our clinic. We included consecutive VKA-naïve patients with non valvular AF, initiated on VKA therapy in our anticoagulation outpatient clinic in 2009. During follow-up, adverse events [thrombotic/vascular events (stroke, acute coronary syndrome, acute heart failure and cardiac death), major bleeding and death], and VKA cessation were recorded. At the end of the follow-up, we determined time within therapeutic range (TTR), using a linear approximation (Rosendaal method). We studied 529 patients (49% male, median age 76), median follow-up 835 days (IQR 719-954). During this period 114 patients stopped VKA treatment. 63 patients suffered a thrombotic/cardiovascular event (5.17%/year, 27 thrombotic/ischaemic strokes), 51 major bleeding (4.19%/year) and 48 died (3.94%/year). Median TTR was 54% (34-57). On multivariate analysis (adjusted by CHA2DS2-VASc score), VKA cessation was associated with death [Hazard Ratio (HR) 3.43; p<0.001], stroke [4.21; p=0.001] and thrombotic/cardiovascular events [2.72; p<0.001]. Independent risk factors for major bleeding were age [1.08; p<0.001], previous stroke [1.85; p=0.049], and TTR [0.97; p=0.001], but not VKA cessation. In conclusion, in AF patients AF, VKA cessation is independently associated with mortality stroke and cardiovascular events. Specifically, VKA cessation independently increased the risk of stroke, even after adjusting for CHA2DS2-VASc score. TTR was an independent risk factor for major bleeding following initiation of VKA therapy.

The HAS-BLED score has better prediction accuracy for major bleeding than CHADS2 or CHA2DS2-VASc scores in anticoagulated patients with atrial fibrillation.

OBJECTIVES: The aim of this study was to test the hypothesis that a specific bleeding risk score, HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol concomitantly), was better at predicting major bleeding compared with CHADS2 (congestive heart failure, hypertension, 75 years of age or older, diabetes mellitus, and previous stroke or transient ischemic attack) and CHA2DS2-VASc (congestive heart failure, hypertension, 75 years of age and older, diabetes mellitus, previous stroke or transient ischemic attack, vascular disease, 65 to 74 years of age, female) in anticoagulated atrial fibrillation (AF) patients. BACKGROUND: The CHADS2 and CHA2DS2-VASc scores are well-validated stroke risk prediction scores for AF, but are also associated with increased bleeding and mortality. METHODS: We recruited 1,370 consecutive AF patients (49% male; median age, 76 years) receiving oral anticoagulation therapy from our outpatient anticoagulation clinic, all of whom were receiving acenocoumarol and had an international normalized ratio between 2.0 and 3.0 during the preceding 6 months. During follow-up, major bleeding events were identified by the 2005 International Society on Thrombosis and Haemostasis criteria. Model performance was evaluated by calculating the C-statistic, and the improvement in predictive accuracy was evaluated by calculating the net reclassification improvement and integrated discrimination improvement. RESULTS: After a median follow-up of 996 (range, 802 to 1,254) days, 114 patients (3.0%/year) presented with a major bleeding event; 31 of these events were intracranial hemorrhages (0.8%/year). Based on the C-statistic, HAS-BLED had a model performance superior to that of both CHADS2 and CHA2DS2-VASc (both p < 0.001). Both net reclassification improvement and integrated discrimination improvement analyses also show that HAS-BLED was more accurately associated with major bleeding compared with CHADS2 and CHA2DS2-VASc scores. CONCLUSIONS: In anticoagulated AF patients, a validated specific bleeding risk score, HAS-BLED, should be used for assessing major bleeding. The practice of using CHADS2 and CHA2DS2-VASc as a measure of high bleeding risk should be discouraged, given its inferior predictive performance compared with the HAS-BLED score.