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The Reply
LETTER
The Reply: Daniell points to a gap of knowledge in atrial fibrillation. Both European1 and American2 guidelines state that a young man, such as the one portrayed by Daniell, without cardiovascular disease of any other kind, non-hypertensive, without diabetes and without any previous stroke/transient ischemic attack, has a truly “lone” type of atrial fibrillation. This person would qualify in the CHA2DS2-VASc⫽0 category,1 for which the net clinical benefit does not favor anticoagulant therapy. The alternative prophylaxis with aspirin entails a risk of hemorrhage (especially gastrointestinal),3 without any demonstratable benefit. Recommendations in this category may change if advances occur in our ability to further discriminate the risk of stroke, eg, with the use of biomarkers.4 Daniell recalls the isolated reports of intracranial bleeding in these patients. All anticoagulants increase the rate of intracranial bleeding, with a much worse prognosis than ischemic stroke.5 Vitamin K antagonists are particularly prone to this complication, and all novel anticoagulants so far tested in phase III trials, dabigatran etexilate, rivaroxaban, and apixaban, have shown reduced risk of intracranial hemorrhage compared with vitamin K antagonists,6 offering new treatment possibilities. Daniell also is right in reporting the lack of knowledge on the best strategy of rhythm control in such patients. The wider availability of ablation, to “cure” the rhythm disturbance and associated symptoms (not necessarily the prothrombotic condition) without the cardiotoxicity of antiFunding: None. Conflict of Interest: Raffaele De Caterina is coauthor of the latest (2010) ESC Guidelines in Atrial Fibrillation and of its 2012 Focused Update, and has participated in Advisory Boards related to atrial fibrillation therapies for Bayer, Bristol-Myers Squibb, Boehringer-Ingelheim, Daiichi Sankyo, Merck, Pfizer and Sanofi-Aventis (overall: ⬍20,000 US $). Elaine M. Hylek has participated in Advisory Boards related to atrial fibrillation therapies for Bayer, Bristol-Myers Squibb, Boehringer-Ingelheim, Daiichi Sankyo, Merck, Ortho-McNeil and Pfizer (overall: ⬍10,000 US $), and receives support from the NIH (⬎10,000 US $). Authorship: Both authors had access to the data and a role in writing the manuscript.
0002-9343/$ -see front matter © 2012 Published by Elsevier Inc.
arrhythmic drugs, will likely induce more and more such patients to undergo ablation procedures.2 While awaiting specific trials in this specific population of fit athletes, the broad advice contained in our article7 is to use the diagnostic criteria validated in the vast majority of non-athletes, recognizing the limitations in current evidence. Raffaele De Caterinaa Elaine M. Hylekb a
Institute of Cardiology and Center of Excellence on Aging, “G. d’Annunzio” University – Chieti, Italy b Department of Medicine, Boston University School of Medicine, Boston, Mass
http://dx.doi.org/10.1016/j.amjmed.2012.07.024
References 1. Camm AJ, Kirchhof P, Lip GY, et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J. 2010;31(19):2369-2429. 2. Wann LS, Curtis AB, January CT, et al. 2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (updating the 2006 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011;123(1):104-123. 3. Olesen JB, Lip GY, Lindhardsen J, et al. Risks of thromboembolism and bleeding with thromboprophylaxis in patients with atrial fibrillation: A net clinical benefit analysis using a ‘real world’ nationwide cohort study. Thromb Haemost. 2011;106(4):739-749. 4. Hijazi Z, Oldgren J, Andersson U, et al. Cardiac biomarkers are associated with an increased risk of stroke and death in patients with atrial fibrillation: a Randomized Evaluation of Long-term Anticoagulation Therapy (RE-LY) substudy. Circulation. 2012;125(13):1605-1616. 5. Connolly SJ, Eikelboom JW, Ng J, et al. Net clinical benefit of adding clopidogrel to aspirin therapy in patients with atrial fibrillation for whom vitamin K antagonists are unsuitable. Ann Intern Med. 2011; 155(9):579-586. 6. De Caterina R, Husted S, Wallentin L, et al. New oral anticoagulants in atrial fibrillation and acute coronary syndromes: ESC Working Group on Thrombosis-Task Force on Anticoagulants in Heart Disease Position Paper. J Am Coll Cardiol. 2012;59(16):1413-1425. 7. De Caterina R, Hylek EM. Stroke prevention in atrial fibrillation: current status and near-future directions. Am J Med. 2011;124(9):793799.
The Reply: Daniell points to a gap of knowledge in atrial fibrillation. Both European1 and American2 guidelines state that a young man, such as the one portrayed by Daniell, without cardiovascular disease of any other kind, non-hypertensive, without diabetes and without any previous stroke/transient ischemic attack, has a truly “lone” type of atrial fibrillation. This person would qualify in the CHA2DS2-VASc⫽0 category,1 for which the net clinical benefit does not favor anticoagulant therapy. The alternative prophylaxis with aspirin entails a risk of hemorrhage (especially gastrointestinal),3 without any demonstratable benefit. Recommendations in this category may change if advances occur in our ability to further discriminate the risk of stroke, eg, with the use of biomarkers.4 Daniell recalls the isolated reports of intracranial bleeding in these patients. All anticoagulants increase the rate of intracranial bleeding, with a much worse prognosis than ischemic stroke.5 Vitamin K antagonists are particularly prone to this complication, and all novel anticoagulants so far tested in phase III trials, dabigatran etexilate, rivaroxaban, and apixaban, have shown reduced risk of intracranial hemorrhage compared with vitamin K antagonists,6 offering new treatment possibilities. Daniell also is right in reporting the lack of knowledge on the best strategy of rhythm control in such patients. The wider availability of ablation, to “cure” the rhythm disturbance and associated symptoms (not necessarily the prothrombotic condition) without the cardiotoxicity of antiFunding: None. Conflict of Interest: Raffaele De Caterina is coauthor of the latest (2010) ESC Guidelines in Atrial Fibrillation and of its 2012 Focused Update, and has participated in Advisory Boards related to atrial fibrillation therapies for Bayer, Bristol-Myers Squibb, Boehringer-Ingelheim, Daiichi Sankyo, Merck, Pfizer and Sanofi-Aventis (overall: ⬍20,000 US $). Elaine M. Hylek has participated in Advisory Boards related to atrial fibrillation therapies for Bayer, Bristol-Myers Squibb, Boehringer-Ingelheim, Daiichi Sankyo, Merck, Ortho-McNeil and Pfizer (overall: ⬍10,000 US $), and receives support from the NIH (⬎10,000 US $). Authorship: Both authors had access to the data and a role in writing the manuscript.
0002-9343/$ -see front matter © 2012 Published by Elsevier Inc.
arrhythmic drugs, will likely induce more and more such patients to undergo ablation procedures.2 While awaiting specific trials in this specific population of fit athletes, the broad advice contained in our article7 is to use the diagnostic criteria validated in the vast majority of non-athletes, recognizing the limitations in current evidence. Raffaele De Caterinaa Elaine M. Hylekb a
Institute of Cardiology and Center of Excellence on Aging, “G. d’Annunzio” University – Chieti, Italy b Department of Medicine, Boston University School of Medicine, Boston, Mass
http://dx.doi.org/10.1016/j.amjmed.2012.07.024
References 1. Camm AJ, Kirchhof P, Lip GY, et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J. 2010;31(19):2369-2429. 2. Wann LS, Curtis AB, January CT, et al. 2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (updating the 2006 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011;123(1):104-123. 3. Olesen JB, Lip GY, Lindhardsen J, et al. Risks of thromboembolism and bleeding with thromboprophylaxis in patients with atrial fibrillation: A net clinical benefit analysis using a ‘real world’ nationwide cohort study. Thromb Haemost. 2011;106(4):739-749. 4. Hijazi Z, Oldgren J, Andersson U, et al. Cardiac biomarkers are associated with an increased risk of stroke and death in patients with atrial fibrillation: a Randomized Evaluation of Long-term Anticoagulation Therapy (RE-LY) substudy. Circulation. 2012;125(13):1605-1616. 5. Connolly SJ, Eikelboom JW, Ng J, et al. Net clinical benefit of adding clopidogrel to aspirin therapy in patients with atrial fibrillation for whom vitamin K antagonists are unsuitable. Ann Intern Med. 2011; 155(9):579-586. 6. De Caterina R, Husted S, Wallentin L, et al. New oral anticoagulants in atrial fibrillation and acute coronary syndromes: ESC Working Group on Thrombosis-Task Force on Anticoagulants in Heart Disease Position Paper. J Am Coll Cardiol. 2012;59(16):1413-1425. 7. De Caterina R, Hylek EM. Stroke prevention in atrial fibrillation: current status and near-future directions. Am J Med. 2011;124(9):793799.