Published online before print August 3, 2006, doi: 10.1161/01.STR.0000237185.42295.36
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(Stroke. 2006;37:2205.)
© 2006 American Heart Association, Inc.
Letters to the Editor |
Eligibility for Anticoagulation in Elderly Patients With Atrial Fibrillation
Otsuki Hospital, Kochi, Japan
Department of Internal Medicine, University of Tokyo, Tokyo, Japan
To the Editor:
Hylek et al concluded in a recent publication that hospitalized elderly patients with atrial fibrillation (AF) may not be optimal candidates for anticoagulation therapy because of their many contraindications.1 However, hospitalized patients enrolled in this study may not be representative of the patients with AF and the results are not necessarily generalizable to clinical practice including outpatients, because most of patients with AF appears to be managed by the general practitioner, and in fact, only one-third of patients with AF have been admitted for AF.2 In contrast to the high rate (48%) of contraindication in hospitalized patients, recent prospective studies have shown that only 10% to 25% of outpatients with AF have contraindications for anticoagulation.3–5 In general, hospitalized patients are liable to have frailty and comorbidity compared with outpatients.
In order to study relations between antithrombotic therapy for AF and outcome events, we enrolled consecutive outpatients with AF who attended our clinic from April 1997 to April 2005. All patients were followed-up for at least >1 year. Treatment was left to the decision of each attending general practitioner. In this cohort, we prospectively assessed eligibility for anticoagulation and prescription rate of warfarin. Of 120 patients with AF, 112 (93.3%) had at least 1 or more risk factors for stroke and 88 (73.3%) were at high risk for stroke according to a risk stratification scheme.6 The mean age of the high-risk patients was 77 years and 58 (65.9%) of them were 75 years and older. Of the high-risk patients, contraindication for anticoagulation was identified in only 11 (12.5%) patients: 1 had documented gastric ulcer, 1 had documented gastro-intestinal bleeding, 5 had dementia, 1 had alcoholism, and 3 had poor clinic compliance. Warfarin was prescribed in 74 (61.7%) of all patients and 69 (78.4%) patients of the high-risk patients. Thus, results of previous studies and ours suggest that warfarin can be used in the majority of elderly outpatients at high risk for stroke as good candidates for anticoagulation in actual clinical practice. Physicians should make further efforts to perform anticoagulation for stroke prevention because warfarin is underused even in eligible patients with AF to date.7
Acknowledgments
Disclosures
None.
References
1. Hylek EM, D’Antonio J, Evans-Molina C, Shea C, Henault LE, Regan S. Translating the results of randomized trials into clinical practice: the challenge of warfarin candidacy among hospitalized elderly patients with atrial fibrillation. Stroke. 2006; 37: 1075–1080.
2. Lip GY, Golding DJ, Nazir M, Beevers DG, Child DL, Fletcher RI. A survey of atrial fibrillation in general practice: the West Birmingham Atrial Fibrillation Project. Br J Gen Pract. 1997; 47: 285–289.[Medline] [Order article via Infotrieve]
3. Kalra L, Yu G, Perez I, Lakhani A, Donaldson N. Prospective cohort study to determine if trial efficacy of anticoagulation for stroke prevention in atrial fibrillation translates into clinical effectiveness. BMJ. 2000; 320: 1236–1239.
4. Ono A, Fujita T. Low-intensity anticoagulation for stroke prevention in elderly patients with atrial fibrillation: efficacy and safety in actual clinical practice. J Clin Neurosci. 2005; 12: 891–894.[CrossRef][Medline] [Order article via Infotrieve]
5. Ruiz Ortiz M, Romo Penas E, Franco Zapata MF, Mesa Rubio D, Anguita Sanchez M, Lopez Granados A, Arizon del Prado JM, Valles Belsue F. Oral anticoagulation in patients aged 75 years or older with chronic non-valvar atrial fibrillation: effectiveness and safety in daily clinical practice. Heart. 2005; 91: 1225–1226.
6. Lip GY. Thromboprophylaxis for atrial fibrillation. Lancet. 1999; 353: 4–6.[CrossRef][Medline] [Order article via Infotrieve]
7. Bungard TJ, Ghali WA, Teo KK, McAlister FA, Tsuyuki RT. Why do patients with atrial fibrillation not receive warfarin? Arch Intern Med. 2000; 160: 41–46.
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