Do Current Guidelines Result in Overuse of Warfarin Anticoagulation in Patients With Atrial Fibrillation?
Authors: Robert G. Hart
Journal: Annals of Internal Medicine (2009)

Editorials1 September 2009Do Current Guidelines Result in Overuse of Warfarin Anticoagulation in Patients With Atrial Fibrillation?Robert G. Hart, MD and Jonathan L. Halperin, MDRobert G. Hart, MDFrom University of Texas Health Science Center, San Antonio, TX 78229, and Mount Sinai Medical Center, New York, NY 10029.Search for more papers by this author and Jonathan L. Halperin, MDFrom University of Texas Health Science Center, San Antonio, TX 78229, and Mount Sinai Medical Center, New York, NY 10029.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-151-5-200909010-00012 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Recommendations for identifying patients with nonvalvular atrial fibrillation who are at low, moderate, or high risk for thromboembolism have recently converged, advocating almost identical risk-stratification criteria (1–3). The widely promulgated CHADS2 scheme uses a system that assigns 1 point each for congestive heart failure, hypertension, age 75 years or older, and diabetes mellitus and 2 points for previous stroke or transient ischemic attack (4). Anticoagulation is generally not recommended for patients with atrial fibrillation who are at low risk for thromboembolism (CHADS2 score of 0; about 20% of patients with atrial fibrillation, who face an average stroke risk of 1% ...References1. Hart RG, Pearce LA. Current status of stroke risk stratification in patients with atrial fibrillation. Stroke. 2009;40:2607-10. [PMID: 19461020] CrossrefMedlineGoogle Scholar2. Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, et al; American College of Cardiology. American Heart Association Task Force on Practice Guidelines. ACC/AHA/ESC 2006 Guidelines 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 European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation. 2006;114:257-354. [PMID: 16908781] MedlineGoogle Scholar3. Singer DE, Albers GW, Dalen JE, Fang MC, Go AS, Halperin JL, et al; American College of Chest Physicians. Antithrombotic therapy in atrial fibrillation: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133:546S-592S. [PMID: 18574273] CrossrefMedlineGoogle Scholar4. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. 2001;285:2864-70. [PMID: 11401607] CrossrefMedlineGoogle Scholar5. Singer DE, Chang Y, Fang MC, Borowsky LH, Pomernacki NK, Udaltsova N, et al. The net clinical benefit of warfarin anticoagulation in atrial fibrillation. Ann Intern Med. 2009;151:297-305. LinkGoogle Scholar6. Go AS, Hylek EM, Borowsky LH, Phillips KA, Selby JV, Singer DE. Warfarin use among ambulatory patients with nonvalvular atrial fibrillation: the anticoagulation and risk factors in atrial fibrillation (ATRIA) study. Ann Intern Med. 1999;131:927-34. [PMID: 10610643] LinkGoogle Scholar7. Connolly SJ, Pogue J, Eikelboom J, Flaker G, Commerford P, Franzosi MG, et al; ACTIVE W Investigators. Benefit of oral anticoagulant over antiplatelet therapy in atrial fibrillation depends on the quality of international normalized ratio control achieved by centers and countries as measured by time in therapeutic range. Circulation. 2008;118:2029-37. [PMID: 18955670] CrossrefMedlineGoogle Scholar8. Fang MC, Go AS, Chang Y, Hylek EM, Henault LE, Jensvold NG, et al. Death and disability from warfarin-associated intracranial and extracranial hemorrhages. Am J Med. 2007;120:700-5. [PMID: 17679129] CrossrefMedlineGoogle Scholar9. Arima H, Hart RG, Colman S, Chalmers J, Anderson C, Rodgers A, et al; PROGRESS Collaborative Group. Perindopril-based blood pressure-lowering reduces major vascular events in patients with atrial fibrillation and prior stroke or transient ischemic attack. Stroke. 2005;36:2164-9. [PMID: 16141420] CrossrefMedlineGoogle Scholar10. Glynn RJ, Danielson E, Fonseca FA, Genest J, Gotto AM, Kastelein JJ, et al. A randomized trial of rosuvastatin in the prevention of venous thromboembolism. N Engl J Med. 2009;360:1851-61. [PMID: 19329822] CrossrefMedlineGoogle Scholar11. Stroke Risk in Atrial Fibrillation Working Group. Comparison of 12 risk stratification schemes to predict stroke in patients with nonvalvular atrial fibrillation. Stroke. 2008;39:1901-10. [PMID: 18420954] CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAffiliations: From University of Texas Health Science Center, San Antonio, TX 78229, and Mount Sinai Medical Center, New York, NY 10029.Disclosures: None disclosed.Corresponding Author: Robert G. Hart, MD, Department of Neurology, University of Texas Health Science Center, 7703 Floyd Curl Drive, MC 7883, San Antonio, TX 78229-3900; e-mail, [email protected]edu.Current Author Addresses: Dr. Hart: Department of Neurology, University of Texas Health Science Center, 7703 Floyd Curl Drive, MC 7883, San Antonio, TX 78229-3900.Dr. Halperin: The Zena and Michael A. Wiener Cardiovascular Institute, The Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Box 1030, Mount Sinai Medical Center, Fifth Avenue at 100th Street, New York, NY 10029-6574. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoThe Net Clinical Benefit of Warfarin Anticoagulation in Atrial Fibrillation Daniel E. Singer , Yuchiao Chang , Margaret C. Fang , Leila H. Borowsky , Niela K. Pomernacki , Natalia Udaltsova , and Alan S. Go The Net Clinical Benefit of Warfarin Anticoagulation in Atrial Fibrillation Henry Bussey Metrics Cited byWarfarin for Prevention of Thrombosis Among Long-Term Care Residents with Atrial Fibrillation: Evidence of Continuing Low Use Despite Consideration of Stroke and Bleeding RiskNew Approaches to Stroke Prevention in Atrial FibrillationThe Net Clinical Benefit of Warfarin Anticoagulation in Atrial FibrillationHenry Bussey, PharmD 1 September 2009Volume 151, Issue 5Page: 355-356KeywordsAbsolute risk reductionAtrial fibrillationHemorrhageHypertensionIschemic strokeMedical risk factorsNeurologyPatient advocacyStrokeThromboembolism ePublished: 1 September 2009 Issue Published: 1 September 2009 Copyright & PermissionsCopyright © 2009 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...