Atrial fibrillation and atherothrombosis: The importance of anticoagulation

We read with interest the article of Goto et al1 about the prevalence and prognostic impact of atrial fibrillation (AF) in patients with atherothrombosis. For this purpose, authors compared the AF and non-AF patients from the REACH registry. In this study, stable outpatients with established atherothrombosis or ≥3 atherothrombotic risk factors were included. Interestingly, the prevalence of AF was common, which ranged from 6.2% to 13.7% according to the different clinical profile. Notably, AF was associated with more frequent fatal and nonfatal cardiovascular outcomes. Surprisingly, in these patients at high risk of atherothrombosis, only 53.1% were treated with oral anticoagulants. Even with high CHADS2 scores, anticoagulant use did not exceed.

Despite that AF is the most frequent arrhythmia found in clinical practice, the management of AF is far from optimal.2 The REACH is a good example of this, but these findings are not limited to the REACH data; it is a worldwide problem.3, 4 Thus, in hypertensives with chronic ischemic heart disease, the proportion of patients with AF was 16.7%. In this study, the subgroup of patients with AF had more comorbidities. Moreover, blood pressure and fasting serum glucose were worse controlled. Despite the high cardioembolic risk of this population, about one third of the patients with AF were not taking anticoagulants.

The poorer prognosis of patients with AF is related not only with the worse clinical profile but also with a worse therapeutic approach.4 Although AFFIRM stated that treatment of patients with AF and a high risk for stroke or death, rhythm-control strategy offered no survival advantage over a rate-control strategy; post hoc analyses showed that sinus rhythm was either an important determinant of survival or a marker for other factors associated with survival that were not recorded, determined, or included in the survival model and also that warfarin use improved survival.5 It is likely that the results obtained from this and other trials could lead some physicians to decrease the perception of risk for AF, and as a result, to underuse anticoagulants.3, 4 All these data emphasize the importance to implement the information about the real risk of AF and atherothrombosis, and to generalize the use of anticoagulants in high-risk patients.