Importance of Risk Reassessment in Patients With Atrial Fibrillation in Guidelines: Assessing Risk as a Dynamic Process

The appropriate use of oral anticoagulants (OACs) for prevention of stroke in atrial fibrillation (AF) relies on the convenient and accurate stroke risk-prediction scheme: namely, the CHA(2)DS(2)-VASc score. As patients with AF would become older and accumulate more comorbidities, their risks-for example, as reflected by the CHA(2)DS(2)-VASc scoresdare not static and could increase over time. The available data demonstrated that follow-up and D CHA(2)DS(2)-VASc scores perform better than the baseline CHA(2)DS(2)-VASc score in the prediction of ischemic stroke. Approximately 90% of initially low-risk patients would have a Delta CHA(2)DS(2)-VASc score >= 1 before the occurrence of ischemic stroke. Apart from risk of stroke, the risk of bleeding for patients with AF is also highly dynamic. For example, the accuracies of the follow-up or Delta Hypertension, Abnormal Renal and Liver Function, Stroke, Bleeding, Labile INR, Elderly, Drugs or Alcohol (HAS-BLED) score in the prediction of major bleeding was significantly higher than that of the baseline HAS-BLED score. Most importantly, the risks of stroke and major bleeding were higher within several months after patients had changes (increases) in their stroke-or bleeding-risk scores. Therefore, risk profiles of patients with AF should be reassessed regularly so that OACs could be prescribed in a timely manner once patients are no longer at low risk for stroke, and modifiable risk factors for bleeding could be corrected. More efforts are necessary to incorporate clear and easy-to-follow recommendations about risk reassessment into the guidelines to improve AF patient care.