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(Circulation. 2001;103:e79.)
© 2001 American Heart Association, Inc.

Correspondence

Implications of Stroke Risk Criteria on the Anticoagulation Decision in Nonvalvular Atrial Fibrillation

Paul A. Tunick, MD; Itzhak Kronzon, MD

New York University School of Medicine, New York, NY

To the Editor:

Go et al¹ made the important point that the age threshold used to assign patients to a high-risk group for stroke with nonvalvular atrial fibrillation (NVAF) markedly affects the number of people who will be candidates for warfarin. The number of those having a low enough risk to be candidates for aspirin rather than warfarin may vary widely depending on which age cutoff is used.

We strongly agree that risk assessment is crucial in deciding which patients to anticoagulate with warfarin. A potent risk factor for stroke was identified in patients with NVAF in the Stroke Prevention in Atrial Fibrillation III (SPAF-III) study, namely significant aortic atherosclerosis as seen on transesophageal echocardiography.² Such aortic lesions have previously been shown to result in a 12% stroke risk at 1 year in patients with sinus rhythm.³ All of the patients in SPAF-III were classified a priori as having "high risk" NVAF (because of advanced age, hypertension, or previous stroke). However, the high-risk patients in SPAF-III who did not have significant aortic atherosclerosis actually had a low risk of stroke at 1 year (1.2%; lower than that of "low risk" NVAF patients in general). This low risk was found whether the patients were treated with full anticoagulation with warfarin (international normalized ratio of 2 to 3) or only with aspirin plus fixed, low-dose warfarin (and a subtherapeutic international normalized ratio). If the NVAF patients did have significant aortic atherosclerosis, their stroke risk was 12% at 1 year, and their risk . . . [Full Text of this Article]