What are the key considerations for initiating anticoagulation therapy in patients with atrial fibrillation?

Key considerations for initiating anticoagulation therapy in patients with atrial fibrillation include:

• Assess the patient's stroke risk using the CHA₂DS₂-VASc score; anticoagulation is recommended for those with a score of 2 or above, and should be considered for men with a score of 1, taking into account bleeding risk.
• Discuss the benefits and risks of anticoagulation with the patient, emphasizing that for most people the benefits outweigh the bleeding risks, but for those with increased bleeding risk, careful monitoring is essential.
• Choose anticoagulant therapy based on clinical risk profiles, patient preferences, and contraindications, including consideration of direct-acting oral anticoagulants (DOACs) such as apixaban, dabigatran, edoxaban, and rivaroxaban, which are preferred options when suitable.
• If DOACs are contraindicated, not tolerated, or unsuitable, offer a vitamin K antagonist (e.g., warfarin), with consideration of patient stability and time in therapeutic range if already on warfarin.
• Do not withhold anticoagulation solely based on age or risk of falls.
• Engage in shared decision-making and provide a personalised package of care including education on stroke prevention, anticoagulation management, and support resources.
• Consider renal function and other contraindications per British National Formulary and MHRA guidance when selecting and dosing anticoagulants.

These considerations ensure safe, effective, and patient-centred initiation of anticoagulation therapy in atrial fibrillation.