Correspondence
Letter by Spiegel et al Regarding Article, “Net
Clinical Benefit of Warfarin in Patients With
Atrial Fibrillation: A Report From the Swedish
Atrial Fibrillation Cohort Study”
safely. If there is at least minor valvular dysfunction and the
CHA2DS2-VASc score is ⬎0 (which is the case in the overwhelming
majority of our patients), we can administer warfarin safely
(CHA2DS2-VASc stands for C, Congestive heart failure; H, Hypertension; A2, Age ⱖ75 years 2 points; D, Diabetes mellitus; S, Stroke
or previous thrombembolic event 2 points; V, Vascular disease; A,
Age 65–74 years; and Sc, Sex category female). If the CHA2DS2VASc score equals 0 (ie, patients with very low risk of thromboembolic events), oral anticoagulation may not be needed (depending on
other risk factors).
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To the Editor:
As physicians dealing with cardiac rehabilitation, we appreciate
the findings of the Swedish Atrial Fibrillation Cohort Study,1
because we are frequently faced with scenarios when it is impossible
to differentiate between different types of atrial fibrillation (AF)—in
particular, secondary AF and valvular AF. Because most of our
patients have both coronary heart disease and at least minor valvular
dysfunction, it is practically impossible to make an exact classification into valvular or nonvalvular AF. Because we would like to
maximize the chance of preventing thromboembolic events and
minimize the risk of intracranial hemorrhages and major bleeding, it
is vital to rely on recent evidence with regard to oral anticoagulation
therapy. According to new evidence,2 alternative oral anticoagulation therapies such as rivaroxaban have been shown to be noninferior
to warfarin in nonvalvular AF.2 In addition, rivaroxaban was
associated with a lower risk of intracranial and fatal bleeding.2 There
is, however, no evidence in terms of applying rivaroxaban in valvular
AF. In most of our patients, however, we are faced with the dilemma
either to administer warfarin, with the consequence of a higher
bleeding risk, or to administer rivaroxaban, with the risk of making
the wrong decision because of (at least minor) valvular dysfunction
in the majority of our patients, for which rivaroxaban has not been
tested.
The results of this study dissolve this dilemma: If there is no
valvular dysfunction or replacement, we can administer rivaroxaban
Disclosures
None.
Rainer Spiegel, MD, PhD
Tobias Lorenz, MD, MSc
Patrick Konietzny, MD
Klinik Adelheid
Unterägeri, Switzerland
References
1. Friberg L, Rosenqvist M, Lip GYH. Net clinical benefit of warfarin in
patients with atrial fibrillation: a report from the Swedish Atrial Fibrillation Cohort Study. Circulation. 2012;125:2298 –2307.
2. Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE, Hacke W, Breithardt
G, Halperin JL, Hankey GJ, Piccini JP, Becker, RC, Nessel, CC, Paolini
JF, Berkowitz SD, Fox KAA, Califf RM, and the Rocket AF Steering
Committee. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation.
N Engl J Med. 2011;365:883– 891.
(Circulation. 2012;126:e322.)
© 2012 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIRCULATIONAHA.112.119727
e322
Letter by Spiegel et al Regarding Article, ''Net Clinical Benefit of Warfarin in Patients
With Atrial Fibrillation: A Report From the Swedish Atrial Fibrillation Cohort Study''
Rainer Spiegel, Tobias Lorenz and Patrick Konietzny
Downloaded from http://circ.ahajournals.org/ by guest on June 18, 2017
Circulation. 2012;126:e322
doi: 10.1161/CIRCULATIONAHA.112.119727
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