Risk-benefit assessment of oral anticoagulation in atrial fibrillation using virtual clinical trials

In atrial fibrillation virtual populations at CHA2DS2-VA=2, long-term continuous rhythm monitoring with OAC lowers stroke risk (HR 0.92) but increases major bleeding (HR 1.17) versus no screening.

• Why it matters: The population-level balance between stroke prevention and OAC-related major bleeding across AF risk strata is uncertain, and definitive randomized evidence is costly and slow.
• What they did: A state-transition Markov-like model synthesized multiple clinical sources to simulate lifetime stroke, major bleeding, and death, and compared systematic screening-triggered OAC with rhythm-guided “pill-in-pocket” versus continuous OAC.
• The result: Time-to-benefit was shorter than time-to-harm for CHA2DS2-VA>4, while pill-in-pocket OAC showed no stroke/mortality difference (HR 1.03) but reduced bleeding (HR 0.81) in elevated bleeding-risk patients, with results sensitive to adherence and bleeding risk.

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