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Achieving a good balance between the benefit of anticoagulation in preventing thrombotic events and its currently unavoidable risk of bleeding is crucial in patients with any of the indications to oral anticoagulants, including those with atrial fibrillation (AF). For long, the fear of bleeding has resulted in a gross underuse of oral anticoagulants.1 The net clinical benefit of oral anticoagulation in AF and venous thromboembolism has definitely improved with the introduction of the non-vitamin K antagonist oral anticoagulants (NOACs), which—besides being much more convenient, with lesser interaction with food or other medications and usable at fixed dosages not requiring routine coagulation monitoring—are also associated with a clear (50%) lower risk of the most ominous type of bleeding—intracranial haemorrhage—and, to a large extent because of this, with a 10% lower mortality.2
Rather than cured, bleeding needs to be prevented, because, when it occurs, it entails the interruption of antithrombotic therapies. Indeed, along with several other reasons such as underlying thromboembolic risk and comorbid conditions, and the risks of transfusion,3 interruption of antithrombotic medications is most likely the best explanation for the tight link between bleeding and the occurrence of thrombotic events.4 Assessing the bleeding risk in AF is therefore certainly not futile for prognostic reasons. While it has been argued that a high risk of bleeding should not deter …
Contributors Both authors contributed equally.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Commissioned; externally peer reviewed.
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