The latest guidelines recommend assessing stroke risk using the CHA2DS2-VASc score and bleeding risk using the ORBIT bleeding risk score in patients with atrial fibrillation NICE CKS.
For most people, the benefit of anticoagulation for stroke prevention outweighs the bleeding risk, but in those with increased bleeding risk, careful monitoring is essential NICE CKS.
Modifiable bleeding risk factors should be addressed, including uncontrolled hypertension, poor INR control in patients on vitamin K antagonists, concomitant use of antiplatelets, SSRIs, NSAIDs, harmful alcohol consumption, and reversible causes of anaemia NICE CKS.
Monitoring and support to modify these risk factors are recommended, and discussions about risks and benefits should be shared with the patient, considering their individual characteristics and preferences NICE CKS.
Use of the ORBIT score is preferred for predicting bleeding risk, as it has higher accuracy than other tools, and regular re-evaluation of bleeding risk is advised NICE NG196.
Anticoagulant options include DOACs (apixaban, dabigatran, edoxaban, rivaroxaban) as first-line treatment for eligible patients, with warfarin as an alternative if DOACs are contraindicated or not tolerated NICE CKS,NICE CKS.
Specific contraindications for DOACs include prosthetic heart valves and antiphospholipid syndrome, where warfarin is preferred NICE CKS.