American Heart Journal
Volume 157, Issue 5 , Page e29, May 2009

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

  • on Behalf of the REACH Registry Investigators

Department of Medicine, Tokai University School of Medicine, Isehara, Japan

VA Boston Healthcare System and Brigham and Women's Hospital, Boston, MA

INSERM U-698, Université Paris 7, AP-HP, Paris, France

Article Outline

 

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:

- Although the risk of thrombotic events is higher in patients with a history of AF than in those without, the risk of severe bleeding is also higher.1, 4

- Most patients with established atherothrombosis are also candidates for long-term antiplatelet therapy, sometimes using protracted combination antiplatelet therapy, particularly in patients with drug-eluting coronary stents.

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.”

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References 

  1. Goto S, Bhatt DL, Rother J, et al. Prevalence, clinical profile, and cardiovascular outcomes of atrial fibrillation patients with atherothrombosis. Am Heart J. 2008;156:855–863.e2
  2. Goto S. Cardiovascular risk factors in patients at high risk of atherothrombosis: what can be learned from registries?. Thromb Haemost. 2008;100:611–613
  3. Toyoda K, Yasaka M, Iwade K, et al. Dual antithrombotic therapy increases severe bleeding events in patients with stroke and cardiovascular disease: a prospective, multicenter, observational study. Stroke. 2008;39:1740–1745
  4. Hylek EM, Evans-Molina C, Shea C, et al. Major hemorrhage and tolerability of warfarin in the first year of therapy among elderly patients with atrial fibrillation. Circulation. 2007;115:2689–2696
  5. Manzano-Fernandez S, Pastor FJ, Marin F, et al. Increased major bleeding complications related to triple antithrombotic therapy usage in patients with atrial fibrillation undergoing percutaneous coronary artery stenting. Chest. 2008;134:559–567

PII: S0002-8703(09)00158-6

doi:10.1016/j.ahj.2009.03.003

Refers to article:

  • Atrial fibrillation and atherothrombosis: The importance of anticoagulation

    Carlos Escobar, Vivencio Barrios
    American Heart Journal May 2009 (Vol. 157, Issue 5, Page e27)

American Heart Journal
Volume 157, Issue 5 , Page e29, May 2009

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