Balancing bleeding and thrombotic risk with new oral anticoagulants in patients with atrial fibrillation

Abstract

Atrial fibrillation (AF) markedly increases the risk of stroke. Warfarin is highly effective for the prevention of stroke in such patients, but it is difficult to use and causes bleeding. Three new oral anticoagulants have been approved for stroke prevention in AF patients, and are at least as effective as warfarin with better bleeding profiles. These new agents have changed and simplified our approach to stroke prevention, as the threshold for initiation of oral anticoagulation is lower. All patients with AF should be risk assessed using the CHA2DS2-VASc score, and all patients with a score of 1 or above (except women with female sex as their only risk factor on the CHA2DS2-VASc score) should be considered for oral anticoagulation with one of the new agents. Formal bleeding risk assessment is essential, and can be done by using the well-validated HAS-BLED score.

Developing a Conversation Aid to Support Shared Decision Making: Reflections on Designing Anticoagulation Choice

“…The classic medical formulation of the problem of anticoagulation is to set the benefits of stroke prevention against the harms of bleeding promotion. 19,20 This leads to a tendency to compare or trade off strokes and bleeds, 19,[21][22][23] or to ask the question of how many bleeds are acceptable in exchange for avoiding a stroke. 24,25 Although this formulation follows the decision analytic logic of utility maximization, in practice we found direct comparison of strokes and bleeds to be inadequate in determining what to do as the practical and emotional implications of living with a risk of stroke or bleeds exceed the issues of utility.…”

Is the ORBIT Bleeding Risk Score Superior to the HAS-BLED Score in Anticoagulated Atrial Fibrillation Patients?

“…A high HAS-BLED score is not an excuse to avoid oral anticoagulation but rather to "flag" for more careful review those patients potentially at risk of bleeding. 38 It also helps identify correctable bleeding factors such as uncontrolled blood pressure, labile INR or concomitant aspirin/nonsteroidal anti-inflammatory drug use. 39 …”

Stroke and Bleeding Risk in Atrial Fibrillation: Navigating the Alphabet Soup of Risk‐Score Acronyms (CHADS2, CHA2DS2‐VASc, R2CHADS2, HAS‐BLED, ATRIA, and More)

“…Table shows the performance of the simple HAS‐BLED score vs other bleeding risk‐assessment schemas in AF patients. The HAS‐BLED score is also predictive of intracranial bleeding and has been used to predict bleeding with nonwarfarin anticoagulants . HAS‐BLED is also validated in AF and non‐AF patients, as well as for predicting bleeding in those undergoing bridging and percutaneous coronary interventions …”