Bridging (ie, stopping OAC and providing anticoagulation cover with heparin) should be used in patients with mechanical heart valves but does not appear to be otherwise Appropriate Choice of OAC: Choice of OAC should be made on an individual basis after stroke and bleeding risk assessment and discussion with the patient. Before an NOAC is initiated, the patient s age, body weight, and renal function should be considered to allow for appropriate dose adaptation where necessary. Falls Risk and Cognitive Impairment: In frail patients and those at high risk of falls, an individual risk assessment needs to be undertaken prior to OAC initiation. In cases where the risk is that of mechanical falls, strategies to improve walking/reduce risk of tripping should be explored (ie, walking aids, appropriate footwear, home review to remove trip hazards), whereas neurological assessment is warranted if falls are unexplained. The bene ts of ischemic stroke reduction generally outweigh the risk of harm from serious bleeding with OAC use; one estimate was that Modi able bleeding risk factors Potentially modi able bleeding risk factors Nonmodi able bleeding risk factors Biomarkers Hypertension/elevated SBP INR control (target 2.0-3.0)a ; target TTR 65% Concomitant APTs and NSAIDs Excessive alcohol intake Nonadherence to OAC/APT Avoidance of hazardous hobbies/occupations Avoidance of bridging therapy with OAC Appropriate choice of OAC and correct doseb Extreme frailty excessive falls riskc VKA management strategyd Anemia Reduced platelet count or function Renal impairment (CrCI >30 mL/min) Age (>65 y) Previous major bleeding Severe renal impairment (dialysis or renal transplant) Severe hepatic disease (cirrhosis) Malignancy Genetic factors (eg, CYP 2C9 polymorphisms) Previous stroke, small vessel disease etc Diabetes mellitus Cognitive impairment/dementia Cystatin C/CKD-EPI cTnT-hs vWF (plus other coagulation markers) Figure 2 Risk factors for bleeding with oral anticoagulation and antiplatelet therapy. a For patients receiving VKA treatment. 