Atrial Fibrillation and Anticoagulation: One Size Fits All?

Editorials16 October 2018Atrial Fibrillation and Anticoagulation: One Size Fits All?Jennifer M. Wright, MD and Craig T. January, MD, PhDJennifer M. Wright, MDUniversity of Wisconsin School of Medicine and Public Health, Madison, Wisconsin (J.M.W., C.T.J.)Search for more papers by this author and Craig T. January, MD, PhDUniversity of Wisconsin School of Medicine and Public Health, Madison, Wisconsin (J.M.W., C.T.J.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M18-2355 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail In today's medical practice, stroke and thromboembolism are naturally associated with atrial fibrillation (AF), which was accepted nearly 70 years ago as a predictor of stroke for patients with advanced rheumatic valvular heart disease (1). However, AF in the absence of significant valvular heart disease was not universally accepted as a stroke risk factor until data from the Framingham Heart Study showed an independent association between AF and stroke (2, 3). This outcome discrepancy of early trials was attributed to the relative ages of the different patient populations studied. In Framingham, older patients with AF had a higher stroke risk ...References1. Daley R, Mattingly TW, Holt CL, Bland EF, White PD. Systemic arterial embolism in rheumatic heart disease. Am Heart J. 1951;42:566-81. [PMID: 14877750] CrossrefMedlineGoogle Scholar2. Davis PH, Dambrosia JM, Schoenberg BS, Schoenberg DG, Pritchard DA, Lilienfeld AM, et al. Risk factors for ischemic stroke: a prospective study in Rochester, Minnesota. Ann Neurol. 1987;22:319-27. [PMID: 3674797] CrossrefMedlineGoogle Scholar3. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke. 1991;22:983-8. [PMID: 1866765] CrossrefMedlineGoogle Scholar4. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation: a major contributor to stroke in the elderly. The Framingham Study. Arch Intern Med. 1987;147:1561-4. [PMID: 3632164] CrossrefMedlineGoogle Scholar5. Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med. 2007;146:857-67. [PMID: 17577005] LinkGoogle Scholar6. Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the Euro Heart Survey on atrial fibrillation. Chest. 2010;137:263-72. [PMID: 19762550] doi:10.1378/chest.09-1584 CrossrefMedlineGoogle Scholar7. Chao TF, Liu CJ, Tuan TC, Chen TJ, Hsieh MH, Lip GYH, et al. Lifetime risks, projected numbers, and adverse outcomes in Asian patients with atrial fibrillation: a report from the Taiwan nationwide AF cohort study. Chest. 2018;153:453-66. [PMID: 29017957] doi:10.1016/j.chest.2017.10.001 CrossrefMedlineGoogle Scholar8. Chao TF, Lip GY, Liu CJ, Tuan TC, Chen SJ, Wang KL, et al. Validation of a modified CHA2DS2-VASc score for stroke risk stratification in Asian patients with atrial fibrillation: a nationwide cohort study. Stroke. 2016;47:2462-9. [PMID: 27625386] doi:10.1161/STROKEAHA.116.013880 CrossrefMedlineGoogle Scholar9. January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC, et al; ACC/AHA Task Force Members. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation. 2014;130:e199-267. [PMID: 24682347] doi:10.1161/CIR.0000000000000041 CrossrefMedlineGoogle Scholar10. Shah SJ, Eckman MH, Aspberg S, Go AS, Singer DE. Effect of variation in published stroke rates on the net clinical benefit of anticoagulation for atrial fibrillation. Ann Intern Med. 2018;169:517-27. doi:10.7326/M17-2762 LinkGoogle Scholar Author, Article, and Disclosure InformationAffiliations: University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin (J.M.W., C.T.J.)Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-2355.Corresponding Author: Jennifer M. Wright, MD, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53792; e-mail, [email protected]wisc.edu.Current Author Addresses: Drs. Wright and January: University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53792.This article was published at Annals.org on 25 September 2018. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoEffect of Variation in Published Stroke Rates on the Net Clinical Benefit of Anticoagulation for Atrial Fibrillation Sachin J. Shah , Mark H. Eckman , Sara Aspberg , Alan S. Go , and Daniel E. Singer Metrics Cited byScreening for Atrial Fibrillation—Refining the TargetStroke Rate Variation and Anticoagulation Benefit in Atrial FibrillationJames A. Reiffel, MD 16 October 2018Volume 169, Issue 8Page: 575-576KeywordsAlgorithmsAtrial fibrillationCardiovascular therapyDisclosureMedical risk factorsPopulation statisticsPrevention, policy, and public healthStrokeThromboembolismVascular diseases ePublished: 25 September 2018 Issue Published: 16 October 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...