Should we make the risk stratification process more complex in patients with atrial fibrillation?

We read the recent article by Escobar and Camm1 which proposed a novel approach to risk stratification by encompassing mortality associated with stroke and bleeding, illustrated by data derived from the literature. Although this is an interesting concept, we have some concerns about the usefulness of this risk stratification approach in everyday clinical practice. We fully agree with the message that bleeding risk is not a reason for withholding or not initiating oral anticoagulation (OAC) therapy as reflected in the European Society of Cardiology (ESC) guidelines,2 but the introduction of mortality risk associated with stroke or bleeding could be misleading and in certain cases may hinder the risk stratification process and decision-making. For example, a 70 years male patient with atrial fibrillation (AF) and uncontrolled hypertension, chronic kidney disease, and anaemia has a CHA2DS2-VASc of 2 (which means OAC recommended), but he also has...