In patients with AF who are eligible for OAC, we recommend NOACs over VKA (Strong recommendation, moderate quality evidence). Remark: Patient and caregiver preferences, cost, formulary considerations, anticipated medication adherence or compliance with INR testing and dose adjustment should be incorporated into clinical decision-making. 8. In patients on VKAs with consistently low time in INR therapeutic range (eg, TTR < 65%), we recommend considering interventions to improve TTR or switching to NOACs (Strong recommendation, moderate quality evidence). Remark: Action required if TTR < 65% - implement additional measures (more regular INR tests; review medication adherence; address other factors known to in uence INR control; education/counseling) to improve INR control. 9. In patients with prior unprovoked bleeding, warfarin-associated bleeding, or at high risk of bleeding, we suggest using apixaban, edoxaban, or dabigatran 110 mg (where available) as all demonstrate signi cantly less major bleeding compared with warfarin (Weak recommendation, very low quality evidence). Remark: In patients with prior gastrointestinal bleeding apixaban or dabigatran 110 mg bid may be preferable as they are the only NOACs not associated with an increased risk of gastrointestinal bleeding compared with warfarin. Remark: Dabigatran 150 mg twice daily recommended in patients at high risk of ischemic stroke as only agent/ dose with superior ef cacy compared with warfarin. However, bleeding risk would need to be assessed and patients monitored. Adjusted-Dose Oral VKA Therapy The VKAs are a class of OACs; the most commonly used are the 4-hydroxycoumarins and include warfarin, phenprocoumon, and acenocoumarol.143 Less commonly used VKAs are phenindione and uindione, which are 1,3-indandione derivatives. Geographical variation in VKA popularity is evident, with warfarin commonly used worldwide but acenocoumarol being popular in Spain and phenprocoumon in Germany. In randomized clinical trials, most have used warfarin. 