Many biomarkers (eg, troponin, natriuretic peptides, in ammatory markers, coagulation markers, etc) are also predictive of stroke, bleeding, death, HF, hospitalization,110 and even noncardiovascular conditions such as glaucoma progression (eg, as in the case of growth differentiation factor-15 used in the ABC-bleed score).111 The performance of biomarker-based scores in real-world clinical practice (outside highly selected trial cohorts) has also been disappointing,112,113 given that baseline (or near-baseline) determination of biomarkers to predict bleeding risks after many years is bedeviled by the changing clinical risk pro le of patient s risks as well as modi cation of risk factors. Given that modi able bleeding risk factors should be addressed in all patients, the appropriate and responsible way to use a clinical risk score is to identify those patients at particularly high risk, for appropriate early review and follow-up (eg, in 4 weeks, rather than 4- 6 months) and depending on the outcome of interest, to address the associated modi able risk factors accordingly (Figs 2, 3). A high bleeding risk score is not a reason to withhold OAC, as the net clinical bene t is even greater in those patients with high bleeding risk. While bleeding risk is highly dynamic and depends on many potentially modi able bleeding risk factors,114 simply focusing on bleeding risk assessment using modi able bleeding risk factors alone is an inferior strategy compared with using a validated bleeding risk score which has been designed to formally assess bleeding score.78-80 A comparison of the different bleeding risk scores has been addressed in 2 systematic reviews, and the studies are summarized in e-Table 10. As with stroke risk scores, most bleeding risk scores based on simple clinical risk factors only have modest predictive value for identifying the high risk patients who sustain events (c-indexes approximately 0.6). 