Step 3: We recommend NOACs as first line therapy for OAC. lf VKA therapy is being considered, the SAMe-TT2R2 score can be used to identify patients who are good candidates for this approach. NOACs generally recommended as first line therapy for OAC If considering VKA, calculate Otherwise, regular review/frequent INR checks/ counselling for VKA users NOAC VKA treatment (eg, warfarin) or NOAC Figure 4 Practical management algorithm. CHA2DS2-VASc congestive heart failure, hypertension, age $ 75 (doubled), diabetes, stroke (doubled)- vascular disease, age 65-74 and sex category (female); HAS-BLED hypertension, abnormal renal/liver function (1 point each), stroke, bleeding history or predisposition, labile INR, elderly (0.65), drugs/alcohol concomitantly (1 point each); SAMe-TT2R2 score awarding 1 point for each of the following: sex (female); age <60 y; medical history ($3 comorbidities: hypertension, diabetes, coronary heart disease/myocardial infarction, peripheral artery disease, heart failure, prior stroke, lung disease, liver disease or renal failure); treatments (such as amiodarone); smoking status (double); and race (non-Caucasian, double). See Figure 1, 2, and 3 legends for expansion of other abbreviations. be considerations in choosing an agent (Table 6)124,127, for comparative information. The VKAs are still widely used and are an acceptable alternative with target TTR $ 70%. As outlined in the section Factors Affecting INR Control, we recommend that the SAMe-TT2R2 score be used to help identify patients likely to do well on VKA therapy. Managing Bleeding on OAC Bleeding on VKA: Management of active bleeding on a VKA depends on the severity (Fig 5).202 For all bleeding events, the site of bleeding should be assessed, with mechanical compression where appropriate, the time- point of the last dose of VKA should be obtained, with factors affecting bleeding risk documented (other medications, kidney function, alcohol abuse, other comorbidities) and hemodynamic status assessed (BP, pulse, etc). 