Comparing the Imperfect with the Imperfect: The Imprecise Science of Assessing the Risk and Benefits of Anticoagulation in Atrial Fibrillation
Atrial Fibrillation (AF) is the most common arrhythmia in the United States, with approximately 7 million Americans estimated to have AF by 2020.1,2 A major cause for morbidity and mortality in AF is stroke. Pharmacologic therapy for the prevention of stroke has undergone a renaissance with the advent of newer oral anticoagulants (NOACs) that are safe and effective alternatives to warfarin. However, the decision to initiate anticoagulation remains a subjective assessment of risks versus benefits. Although guided by well-validated risk scores for stroke and bleeding,3,4,5 real world decisions on anticoagulation continue to differ significantly from guidelines, with many patients at high risk not receiving anticoagulation because of a perceived high risk of bleeding, and many low risk patients being anticoagulated due to a perceived low risk of bleeding, the so-called risk-treatment paradox.6 This phenomenon is thought to account for the continued underutilization of oral anticoagulation therapy,7 however, has yet to be validated in a large outpatient based practice. Therefore, the current study by Steinberg et al in this issue of Circulation is a timely effort to better understand and address some of the reasons underlying this risk mismatch in thromboembolic assessment and anticoagulation therapy in a community outpatient based group of patients with stable AF.8
- Received March 23, 2014.
- Accepted March 25, 2014.