Assessment and mitigation of bleeding risk in atrial fibrillation and venous thromboembolism: A Position Paper from the ESC Working Group on Thrombosis, in collaboration with the European Heart Rhythm Association, the Association for Acute CardioVascular Care and the Asia-Pacific Heart Rhythm Society.

Whilst there is a clear clinical benefit of oral anticoagulation (OAC) in patients with atrial fibrillation (AF) and venous thromboembolism (VTE) in reducing the risks of thromboembolism, major bleeding events (especially intracranial bleeds) may still occur and be devastating. The decision to initiate and continue anticoagulation is often based on a careful assessment of both the thromboembolism and bleeding risk. The more common and validated bleeding risk factors have been used to formulate bleeding risk stratification scores, but thromboembolism and bleeding risk factors often overlap. Also, many factors that increase bleeding risk are transient and modifiable, such as variable international normalized ratio values, surgical procedures, vascular procedures, or drug-drug and food-drug interactions. Bleeding risk is also not a static 'one off' assessment based on baseline factors but is dynamic, being influenced by ageing, incident comorbidities, and drug therapies. In this Consensus Document, we comprehensively review the published evidence and propose a consensus on bleeding risk assessments in patients with AF and VTE, with the view to summarizing 'best practice' when approaching antithrombotic therapy in these patients. We address the epidemiology and size of the problem of bleeding risk in AF and VTE, review established bleeding risk factors, and summarize definitions of bleeding. Patient values and preferences, balancing the risk of bleeding against thromboembolism are reviewed, and the prognostic implications of bleeding are discussed. We propose consensus statements that may help to define evidence gaps and assist in everyday clinical practice.

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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2022. For permissions, please email: [e-mail].

Déclaration de conflit d'intérêts

Conflict of interest: A.R.: speaker for Bayer, Daiichi-Sankyo, and Boehringer-Ingelheim. D.A.G.: grants from Bayer, Medtronic. Speaker for Bayer, Boehringer-Ingelheim, and AstraZeneca. D.L.: grants from BMS and Boehringer-Ingelheim; consultant and speaker for BMS, Boehringer-Ingelheim, and Bayer. F.M.: consultant and speaker for AstraZeneca and Boehringer-Ingelheim; grants from Bayer, Boehringer Ingelheim, and Daiichi-Sankyo. G.V.: speaker for AstraZeneca. G.Y.H.L.: consultant and speaker for BMS/Pfizer, Boehringer Ingelheim, and Daiichi-Sankyo. No fees are received personally. H.F.T.: grants from Abbott, Amgen, AstraZeneca, Bayer, Cooks Medical, Boehringer Ingelheim, Boston Scientific, Daichi Sankyo, Medtronic, Novartis, Pfizer, and Sanofi. J.L.F.: Speaker for AstraZeneca, Ferrer, Pfizer, Abbott Medical, Boehringer Ingelheim, Daiichi Sankyo, BMS, and Royi. K.H.: speaker for AstraZeneca, Bayer, and Boehringer-Ingelheim. L.F.: consultant and speaker activities for AstraZeneca, Bayer, BMS/Pfizer, Boehringer Ingelheim, Medtronic, Novartis, Novo, and XO. The other authors have no conflict of interest to declare.