• heart failure
• atrial fibrillation
• oral anticoagulation
• risk stratification
• shared decision making

According to international guidelines, including those from the European Society of Cardiology (ESC), patients with atrial fibrillation and an additional risk factor for thromboembolic events, such as heart failure, should be considered for long-term oral anticoagulation.1 Risk assessment should include the use of the CHA₂DS₂-VASc score, which among other things gives a point for the presence of the signs or symptoms of heart failure (or objective evidence of reduced left ventricular function), as well as for being female or older age (1 point for age 65–74 years, 2 points for age 75 years or older).2 Thus, for the vast majority of patients with heart failure and atrial fibrillation, oral anticoagulation should be the default position, the only exception being those who have excessively high bleeding risk and/or those who (after full discussion) do not wish to take an anticoagulant.

In England, The National Institute for Health and Care Excellence (NICE) also recommends that the CHA₂DS₂-VASc stroke risk score should be used for all patients with atrial fibrillation, and that oral anticoagulation should be ‘offered’ (the strongest level of recommendation) to people with a CHA₂DS₂-VASc score of 2 or above, taking bleeding risk into account.3 As in the ESC guideline,1 the HAS-BLED bleeding risk score is recommended to provide a more objective estimate of bleeding risk—with emphasis on tackling those risk factors for bleeding that may be reversible (such as uncontrolled hypertension, concomitant use of aspirin or non-steroidal anti-inflammatory drugs or harmful alcohol consumption). Of note, several of the factors that are associated with increased bleeding risk are also strongly associated with an increased risk of thromboembolism, making clinical decision-making complex …