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/counselling) 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 associated without 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. 10. For patients with non-valvular AF, when VKAs are used, we suggest the target should be INR 2.0-3.0, with attention to individual TTR, ideally 70% (Ungraded consensus-based statement). Remark: Action required if TTR sub-optimal (ie, <65- 70%) - 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 or consider an NOAC. Remark: When possible, experienced specialized anticoagulation clinics should be utilized for VKA and INR management. 11. 