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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 January 2, 2024 e31

Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation

additional factors may inform decision-making for patients with an intermediate risk of stroke who remain uncertain on deciding anticoagulation. 4.	 Unless an absolute contraindication to antico-

agulation is present, bleeding risk scores have limitation in clinical decision-making because the most commonly used scores (HAS-BLED,5 HEMORR2HAGES,6 and ATRIA7) are based on several clinical factors that indicate higher risks of both stroke and bleeding, and patients with higher risk of bleeding also tend to have a higher risk of stroke. Furthermore, a bleeding risk score cannot be interpreted in isolation because it does not assess the net clinical benefit of anticoagulation or balance the risk of bleeding against the risk of stroke. Population-based studies suggest that the benefits of stroke prevention with oral anticoagulation generally outweigh the risks of bleeding, even in patients determined to be at high risk for bleeding.8,9 Decision-making about oral anticoagulation should be based on consideration of both benefits and harms, not by using bleeding risk scores in isolation, and the best utility of these scores may be identifying potential modifying risk factors.8,9

6.2 Risk-Based Selection of Oral

Anticoagulation: Balancing Risks and Benefits Recommendations for Risk-Based Selection of Oral Anticoagulation: Balancing Risks and Benefits Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations

1 B-R 1 In patients diagnosed with AF who have an estimated

annual risk of stroke or thromboembolic events ≥2%, selection of therapy to reduce the risk of stroke should be based on the risk of thromboembolism, regardless of whether the AF pattern is paroxysmal, persistent, long-standing persistent, or permanent.1–3

1 B-NR 2 In patients with AF at risk for stroke, reevaluation

of the need for and choice of stroke risk reduction therapy at periodic intervals is recommended to reassess stroke and bleeding risk, net clinical benefit, and proper dosing.4,5

Figure 9. Rates of Stroke by Stroke Risk Score Levels in Different Cohorts. Overall stroke rate in atrial fibrillation cohorts in order of descending stroke rate (events per 100 person-years). Reproduced with permission from Quinn et al.4 Copyright 2017 American Heart Association, Inc.

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