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

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.