What are the latest guidelines on the use of anticoagulants in patients with atrial fibrillation, particularly regarding bleeding risk?

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 ¹.

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 ¹.

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 ¹.

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 ¹.

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 ².

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 ¹,³.

Specific contraindications for DOACs include prosthetic heart valves and antiphospholipid syndrome, where warfarin is preferred ³.