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NICE changes advice on bleeding risk tool in updated atrial fibrillation guidance

atrial fibrillation DOACs

NICE has issued several updated recommendations on the diagnosis and management of atrial fibrillation including how to calculate bleeding risk.

In the first update since 2014, NICE said that evidence now shows that ORBIT is the most accurate tool for predicting absolute bleeding risk in people with atrial fibrillation who are starting or having a review of treatment.

The recommendations point out that other risk tools, such as HAS-BLED which was recommended in the previous guideline may need to continue to be used until ORBIT is embedded into clinical systems and there may be a need for training.

Committee members said that a bleeding risk tool should be used to support shared decision making between a patient and healthcare professional and accurately estimating absolute risk was more important than identifying a risk threshold for anticoagulation.

Updates to the previous recommendations also focus on treatment with newer oral anticoagulants.

GPs should discuss with patients that for most people the benefit of anticoagulation outweighs the bleeding risk but for people with an increased risk of bleeding that balance may differ or may require more monitoring.

A direct-acting oral anticoagulant should be offered to people with atrial fibrillation with a CHA2DS2-VASc score of 2 or above, NICE said, or be considered in men with a CHA2DS2-VASc score of 1 taking into account bleeding risk.

Apixaban, dabigatran, edoxaban and rivaroxaban are all recommended as options as per NICE technology appraisal guidance, the recommendations said.

The committee said it decided not to recommend one direct‑acting oral anticoagulant over another, but instead to emphasise that treatment should be tailored to the patient and factors that may impact adherence such as dosing frequency should be taken into account.

Warfarin can be used as an alternative if direct-acting oral anticoagulants are contraindicated, not tolerated or not suitable.

The updated guidelines are likely to lead to a continued trend for reduced use of warfarin and may lead to a reduced need for clinics to monitor patients taking it, NICE said.

Radiofrequency point‑by‑point ablation or treatment should be considered when drug treatment is unsuccessful, unsuitable or not tolerated in people with symptomatic intermittent or persistent symptoms with cryoballoon or laser balloon ablation as alternatives.