CLINICAL QUESTION

Is there an accurate tool to assess bleeding risk in patients with atrial fibrillation (AF) when starting a direct oral anticoagulant (DOAC) to minimize the risk of stroke?

EVIDENCE SUMMARY

Family physicians must consider the balance between thromboembolic disease prevention and major bleeding risks when starting anticoagulation in patients with AF.¹ Although key guidelines recommend the CHA₂DS₂-VASc (congestive heart failure, hypertension, age 75 years or older [doubled], diabetes, stroke/transient ischemic attack/thromboembolism [doubled], vascular disease, age 65 to 74 years, sex category [female]) score to stratify stroke risk, there is less consensus on a risk score for bleeding.^1,2 The HAS-BLED (hypertension, abnormal renal and liver function, stroke, bleeding risk, labile international normalized ratio, elderly [older than 65 years], drug and alcohol use) score is used most often, but it was created for calculating the risk of bleeding events while using warfarin.³ With the use of DOACs increasing in the management of AF, a bleeding risk calculator tailored for patients taking DOACs would be beneficial in guiding patients and clinicians through the decision to start anticoagulation.