<p>When to withhold oral anticoagulation in atrial fibrillation – an overview of frequent clinical discussion topics</p>

Abstract

Stroke prevention with oral anticoagulants in patients with atrial fibrillation predisposes for bleeding. As a result, in select patient groups anticoagulation is withheld because of a perceived unfavorable risk-benefit ratio. Reasons for withholding anticoagulation can vary greatly between clinicians, often leading to discussion in daily clinical practice on the best approach. To guide clinical decision-making, we have reviewed available evidence on the most frequently reported reasons for withholding anticoagulation: previous bleeding, frailty and age, and an overall high bleeding risk.

CHA 2 DS 2 -VASc and HAS-BLED Risk Scores and real-world Oral Anticoagulant Prescribing Decisions in Atrial Fibrillation

“…Notably, the analytic approach used determined that bleeding risk factors including drugs indicating a predisposition to bleeding in the year before diagnosis, hypertension in the year before diagnosis, age at diagnosis and history of a major bleeding were the most important factors in the treatment decision. This is supported by previous research in which approximately 40% of the patients in a Spanish NVAF cohort that ceased OAC treatment did so due to a major bleeding event, indicating that major bleeding has a significant impact on the treatment decision [13][14][15][16]. This is concerning as the literature suggests that in the majority of patients with risk factors indicative of a high risk of stroke and bleeding, OAC treatment offers a net clinical benefit.…”

“…This is concerning as the literature suggests that in the majority of patients with risk factors indicative of a high risk of stroke and bleeding, OAC treatment offers a net clinical benefit. As such it has been suggested in the literature and guidelines that bleeding risk factors should be used as tools to flag high risk patients for closer and more regular follow-ups and consideration of approaches to modify risk factors where possible, rather than as contraindications to OAC treatment [4,[16][17][18][19][20]. Our findings suggest that upcoming revisions of national and international guidelines for the use of OACs could provide further guidance on whether and how to consider bleeding risk factors in OAC treatment decisions.…”

Adherence to anticoagulant guideline for atrial fibrillation: A large care gap among stroke patients in a rural population

“…Dynamic risk assessments, where changes to bleeding risk profiles are monitored, are stronger at predicting major bleeding events and decreasing OAC undertreatment [30]. In patients with non-modifiable OAC contraindications, it is often recommended that NOAC or left atrial appendage closure should be considered for stroke prevention [5,[30][31][32]34]. Furthermore, we could not assess the risk of undertreatment associated with the different types of atrial fibrillation.…”

Thrombotic events and rebleeding after hemorrhage in patients taking direct oral anticoagulants for non-valvular atrial fibrillation

“…Restarting warfarin after major GIB is reportedly associated with significant reductions in thromboembolism and all-cause mortality [ 13 – 15 ]. Meanwhile, anticoagulant interruption is known to be related to increased risks of all-cause mortality and thrombosis, but no decrease in risk of major bleeding [ 16 , 17 ]. However, information on the clinical course after bleeding during DOAC therapy remains limited, and both the incidences of rebleeding and thrombosis and factors associated with the development of such adverse events are uncertain [ 18 ].…”