Assessment and Mitigation of Bleeding Risk in Atrial Fibrillation and Venous Thromboembolism: Executive Summary of a European and Asia-Pacific Expert Consensus Paper

Diana A. Gorog; Ying X. Gue; Tze-Fan Chao; Laurent Fauchier; Jose Luis Ferreiro; Kurt Huber; Stavros V. Konstantinidis; Deirdre A. Lane; Francisco Marin; Jonas Oldgren; Tatjana Potpara; Vanessa Roldan; Andrea Rubboli; Dirk Sibbing; Hung-Fat Tse; Gemma Vilahur; Gregory Y. H. Lip

doi:10.1055/s-0042-1750385

Thrombosis and Haemostasis, Table of Contents

Thromb Haemost 2022; 122(10): 1625-1652
DOI: 10.1055/s-0042-1750385

Review Article

Assessment and Mitigation of Bleeding Risk in Atrial Fibrillation and Venous Thromboembolism: Executive Summary of a European and Asia-Pacific Expert Consensus Paper

Diana A. Gorog^*

¹School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hertfordshire, United Kingdom

²Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom

,

Ying X. Gue

³Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom

,

Tze-Fan Chao

⁴Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan

⁵Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan

,

Laurent Fauchier

⁶Faculty of Medicine, University of Tours, Tours, France

,

Jose Luis Ferreiro

⁷Department of Cardiology, Hospital Universitario de Bellvitge and Ciber Cardiovascular (CIBERCV), L'Hospitalet de Llobregat, Spain

⁸BIOHEART-Cardiovascular Diseases Group, Cardiovascular, Respiratory and Systemic Diseases and Cellular Aging Program, Institut d'Investigació Biomèdica de Bellvitge – IDIBELL, L'Hospitalet de Llobregat, Spain

,

Kurt Huber

⁹3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital and Sigmund Freud University, Medical Faculty, Vienna, Austria

,

Stavros V. Konstantinidis

¹⁰Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany

,

Deirdre A. Lane

³Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom

¹¹Department of Clinical Medicine, Aalborg University, Aalborg, Denmark

,

Francisco Marin

¹²Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca (IMIB-Arrixaca), CIBERCV, Universidad de Murcia, Murcia, Spain

,

Jonas Oldgren

¹³Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden

,

Tatjana Potpara

¹⁴School of Medicine, Belgrade University, Belgrade, Serbia

,

Vanessa Roldan

¹⁵Servicio de Hematología, Hospital Universitario Morales Meseguer, Universidad de Murcia, IMIB-Arrixaca, Murcia, Spain

,

Andrea Rubboli

¹⁶Department of Cardiovascular Diseases - AUSL Romagna, Division of Cardiology, S. Maria delle Croci Hospital, Ravenna, Italy

,

Dirk Sibbing

¹⁷Department of Cardiology, Ludwig-Maximilians-Universität München, München, Germany

¹⁸DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany

,

Hung-Fat Tse

¹⁹Division of Cardiology, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong

,

Gemma Vilahur

²⁰Research Institute Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain

²¹CIBERCV Instituto de Salud Carlos III, Barcelona, Spain

,

Gregory Y. H. Lip ^*

³Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom

¹¹Department of Clinical Medicine, Aalborg University, Aalborg, Denmark

› Author Affiliations

Abstract

While there is a clear clinical benefit of oral anticoagulation 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 for initiating and continuing anticoagulation is often based on a careful assessment of both 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 aging, incident comorbidities, and drug therapies. In this executive summary of a European and Asia-Pacific Expert Consensus Paper, we comprehensively review the published evidence and propose a consensus on bleeding risk assessments in patients with AF and VTE, with a 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, and 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.

Keywords

bleeding - oral anticoagulation - atrial fibrillation - venous thromboembolism - risk assessment

Full Text

References

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