The DOAC Score is a bleeding-risk prediction tool for adults with non-valvular atrial fibrillation treated with direct-acting oral anticoagulants (DOACs).

Derivation and validation

The original derivation and validation study derived the score in 5,684 participants receiving dabigatran 150 mg twice daily in the RE-LY trial, using International Society on Thrombosis and Haemostasis (ISTH) major bleeding as the outcome.
Refined in the GARFIELD-AF registry of 12,296 DOAC-treated atrial fibrillation patients and externally validated in pooled DOAC trials (COMBINE-AF, 25,586 patients) and a Quebec administrative database (RAMQ, 11,945 patients).
Discrimination for major bleeding was modest but consistent, with C-statistics around 0.7 in the derivation cohorts and 0.65–0.7 in validation cohorts, and better performance than HAS-BLED in all four datasets.

Risk gradient

In the RE-LY derivation cohort, approximate 1-year major bleeding risk by DOAC Score category was:

Risk category	DOAC Score	Approximate 1-year major bleeding (RE-LY)
Very low	0–3	about 1% or less
Low	4–5	around 1–2%
Moderate	6–7	around 3–4%
High	8–9	around 5–7%
Very high	10	around 14%

Absolute bleeding rates were lower in some external cohorts, but the stepwise increase in risk from very low to very high groups was preserved.

Use and limitations

Developed for adults with non-valvular atrial fibrillation treated with DOACs. not validated in mechanical heart valves, moderate to severe mitral stenosis, or when DOACs are used solely for venous thromboembolism or other non-atrial fibrillation indications.
Bleeding-risk tools such as the DOAC Score are intended to quantify absolute risk and highlight modifiable factors (for example renal function, antiplatelet or NSAID use, underweight and liver disease).
Contemporary atrial fibrillation guidelines emphasise that bleeding-risk scores should not be used in isolation to decide on anticoagulation, but to support shared decision-making and targeted risk-factor modification.

Direct-Acting Oral Anticoagulants (DOAC) Score