Updated NICE guideline on AF makes new recommendation on bleeding risk calculation

ORBIT is the most accurate tool for predicting absolute bleeding risk in people with atrial fibrillation (AF), according to updated NICE guideline.

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NICE has today published an updated guideline on the diagnosis and management of atrial fibrillation (AF).

The updated guideline addresses several areas where new evidence has become available since publication of the previous guideline in 2014. These include bleeding risk calculation, the role of newer anticoagulants, and ablation.


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Accurate knowledge of bleeding risk supports shared decision making and has practical benefits (for example, increasing patient confidence and willingness to accept anticoagulation treatment when risk is low and prompting discussion of risk reduction when risk is high). According to NICE, evidence shows that ORBIT is the most accurate tool for predicting absolute bleeding risk in people with AF. However, the guideline acknowledges that other bleeding risk tools, including HAS-BLED which NICE’s previous guideline recommended, may need to be used until ORBIT is embedded in clinical pathways and electronic systems.

The guideline recommends anticoagulation with a direct-acting oral anticoagulant should be offered to people with atrial fibrillation and a high risk of stroke (CHA2DS2-VASc score of 2 or above), taking into account the risk of bleeding. For men with a moderate risk of stroke (CHA2DS2-VASc score of 1), anticoagulation with a direct-acting oral anticoagulant should be considered. Apixaban, dabigatran, edoxaban and rivaroxaban are all recommended as options, when used in line with the criteria specified in the relevant NICE technology appraisal guidance.

A vitamin K antagonist (for example warfarin) is recommended as an alternative if direct-acting oral anticoagulants are contraindicated, not tolerated or not suitable.

When drug treatment is unsuccessful, unsuitable or not tolerated in people with symptomatic intermittent or persistent atrial fibrillation the updated guideline says radiofrequency point-by-point ablation should be considered or, if this isn’t suitable, either cryoballoon ablation or laser balloon ablation.

Atrial fibrillation is the most common heart rhythm disorder (affecting approximately 2% of the adult population), and estimates suggest its prevalence is increasing. It is estimated that AF is responsible for approximately 20% of all strokes and is associated with increased mortality. Men are more commonly affected than women and the prevalence increases with age and in underlying heart disease, diabetes, obesity and hypertension.

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