Refined bleeding estimates in adults starting anticoagulants

Oral anticoagulation is prescribed for the treatment and prevention of both venous thromboembolism and systemic embolism or stroke. Although treatment of acute events may require only short term use of anticoagulation, long term use is often prescribed, particularly for stroke prevention in patients with atrial fibrillation. The long term risk of bleeding associated with anticoagulation becomes a major consideration in decisions about treatment. While newer anticoagulants are associated with a lower risk of intracranial bleeding,1 ongoing or future risk of serious bleeding remains a contraindication to use of these agents.

Therefore, although guidelines on anticoagulation for patients with atrial fibrillation have been generally based on an objective assessment of stroke risk,2 3 they acknowledge that providers should also consider the patient’s risk of bleeding. Yet doctors have few objective tools that are broadly recommended. Unlike scores quantifying the risk of stroke, which were used to stratify patients in randomised trials of anticoagulation,1 4 no randomised study has tested the withholding of anticoagulation based on an increased risk of bleeding.

While several scores …