Response to “Atrial fibrillation and atherothrombosis: The importance of anticoagulation” by Escobar C and Barrios V

We are grateful to Drs Barrios and Escobar for their interest in our analysis of atrial fibrillation in the REACH registry.1 Our article highlighted the relatively low use of oral anticoagulants in atrial fibrillation (AF) patients, even when at high risk of stroke.1 We believe that this observation is of importance given the major differences between the often highly selected patient populations enrolled in randomized clinical trials and the patients enrolled into large-scale registries, such as REACH, which are more representative of daily practice.2 This is particularly important when attempting to extend the results of clinical trials to other settings in terms of geography, care providers, patients' ethnicity, comorbidities, and general management.3

The apparent underuse of anticoagulants in patients with established atherothrombosis in REACH must be interpreted in light of several important facts:

In these patients, “triple antithrombotic therapy” is clearly associated with an increased risk of bleeding,5 but the optimal antithrombotic strategy still remains to be defined. We agree with Drs Barrios and Campos, that, as stated in our own conclusion: “Efforts should be devoted to improving the care of these patients, particularly to ensure the appropriate use of oral anticoagulants. There is a need for the optimal antithrombotic therapy among AF patients to be clarified to balance the increased risk of thrombotic events and the increased risk of bleeding associated with combined anticoagulant and antiplatelet therapy.”