title: Bleeding risk assessment and management in atrial fibrillation patients: a position document from the European Heart Rhythm Association, endorsed by the European Society of Cardiology Working Group on Thrombosis.
abstract: Despite the clear net clinical benefit of oral anticoagulation (OAC) in atrial fibrillation (AF) patients at risk for stroke, major bleeding events (especially intra-cranial bleeds) may be devastating events when they do occur. The decision for OAC is often based on a careful assessment of both stroke risk and bleeding risk, but clinical scores for bleeding risk estimation are much less well validated than stroke risk scales. Also, the estimation of bleeding risk is rendered difficult since many of the known factors that increase bleeding risk overlap with stroke risk factors. As well as this, many factors that increase bleeding risk are transient, such as variable international normalized ratio values, operations, vascular procedures, or drug-drug and food-drug interactions. In this Position Document, we comprehensively review the published evidence and propose a consensus on bleeding risk assessments in AF patients, with a view to summarizing 'best practice' when approaching antithrombotic therapy in AF patients. We address the epidemiology and size of the problem of bleeding risk in AF and review established bleeding risk factors. We also summarize definitions of bleeding in the published literature. Patient values and preferences balancing the risk of bleeding against thrombo-embolism is reviewed, and the prognostic implications of bleeding are discussed. We also review bleeding risk stratification and currently published bleeding risk schema. A brief discussion of special situations [e.g. peri-ablation, peri-devices (implantable cardioverter-defibrillator, pacemakers) and presentation with acute coronary syndromes and/or requiring percutaneous coronary interventions/stents and bridging therapy], as well as a discussion of prevention of bleeds and managing bleeding complications, is made. Finally, this document also puts forwards consensus statements that may help to define evidence gaps and assist in everyday clinical practice. Bleeding risk is almost inevitably lower than stroke risk in patients with atrial fibrillation. Nonetheless, identification of patients at high risk of bleeding and delineation of conditions and situations associated with bleeding risk can help to refine antithrombotic therapy to minimize bleeding risk.
authors.affiliation: University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham B18 7QH, UK. g.y.h.lip@bham.ac.uk
authors.forename: Gregory Y H
authors.initials: GY
authors.lastname: Lip
authors.forename: Felicita
authors.initials: F
authors.lastname: Andreotti
authors.forename: Laurent
authors.initials: L
authors.lastname: Fauchier
authors.forename: Kurt
authors.initials: K
authors.lastname: Huber
authors.forename: Elaine
authors.initials: E
authors.lastname: Hylek
authors.forename: Eve
authors.initials: E
authors.lastname: Knight
authors.forename: Deirdre A
authors.initials: DA
authors.lastname: Lane
authors.forename: Marcel
authors.initials: M
authors.lastname: Levi
authors.forename: Francisco
authors.initials: F
authors.lastname: Marin
authors.forename: Gualtiero
authors.initials: G
authors.lastname: Palareti
authors.forename: Paulus
authors.initials: P
authors.lastname: Kirchhof
authors.forename: Jean-Philippe
authors.initials: JP
authors.lastname: Collet
authors.forename: Andrea
authors.initials: A
authors.lastname: Rubboli
authors.forename: Daniela
authors.initials: D
authors.lastname: Poli
authors.forename: John
authors.initials: J
authors.lastname: Camm
mesh_terms: D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects*; D001281:Atrial Fibrillation / Q000453:epidemiology*; D002309:Cardiology / Q000592:standards*; D005060:Europe; D006470:Hemorrhage / Q000139:chemically induced / Q000453:epidemiology*; D006801:Humans; D012307:Risk Factors; D012955:Societies, Medical / Q000592:standards; D020521:Stroke / Q000453:epidemiology / Q000517:prevention & control; D013927:Thrombosis / Q000453:epidemiology* / Q000517:prevention & control
chemical_list: D000925:Anticoagulants