New data show that also lower-risk AF patients benefit from oral anticoagulation
Should Atrial Fibrillation Patients With Only 1 Nongender-Related CHA2DS2-VASc Risk Factor Be Anticoagulated?
Fauchier L, Clementy N, Bisson A, et al.
Stroke. 2016;47: published online ahead of print
BackgroundThe use of oral anticoagulation (OAC) substantially reduces the risk of stroke/systemic embolism (SSE) in patients with atrial fibrillation (AF) and is guided by risk scores . The currently recommended CHA2DS2-VASc risk score is based on age, sex, and the presence of congestive heart failure, hypertension, diabetes, stroke/transient ischemic attack, and vascular disease . However, different guidelines recommend different treatment approaches based on the use of the CHA2DS2-VASc risk score [3-5]:
- the AHA/ACC guidelines recommend OAC to high-risk AF patients with at least 2 nongender-related (NGR) stroke risk factors (CHA2DS2-VASc >2 in males and >3 in females),
- the ESC and NICE guidelines recommend identifying first the low-risk AF patients who do not need any antithrombotic therapy, after which effective stroke prevention is offered to those with at least 1 NGR stroke risk factor.
- The annual rate of the composite end point of SSE in non-anticoagulated AF patients with 1 NGR stroke risk factor relative to the group with 0 NGR stroke risk factor was: 2.09%; 95% CI: 1.37–3.18, which corresponded to an adjusted HR: 2.82%; 95% CI: 1.32–6.04.
- The annual rates of death and the composite end point of death/SSE were 3.78% and 5.59% respectively, in non-anticoagulated patients with 1 NGR stroke risk factor, and 0.87% and 1.42% respectively, in non-anticoagulated patients with 0 NGR stroke risk factors.
- The annual rates of bleeding events in non-anticoagulated AF patients with 0 or 1 CHA2DS2-VASc factor were: major bleeding: 0.65%; intracranial haemorrhage: 0.43%. No significant difference was seen in patients without OACs between 0 or 1 NGR stroke risk factor.
- Net clinical benefit: When the benefit of ischaemic stroke reduction was balanced against the increased risk of intracranial haemorrhage among patients with 1 NGR stroke risk factor, the net clinical benefit was positive in favour of OAC use VS. no antithrombotic therapy or antiplatelet therapy use.
Net clinical benefit was negative for antiplatelet therapy use vs. no antithrombotic therapy.
ConclusionAmong AF patients with 1 NGR stroke risk factor, OAC use was associated with a positive net clinical benefit for the prevention of stroke and thromboembolic events. These data support a treatment strategy focussed not only on recommending OAC to high-risk, but also to lower-risk AF patients with 1 NGR stroke risk factor.
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