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Do Current Guidelines Result in Overuse of Warfarin Anticoagulation in Patients With Atrial Fibrillation?

Robert G. Hart, MD; and Jonathan L. Halperin, MD
[+] Article, Author, and Disclosure Information

From University of Texas Health Science Center, San Antonio, TX 78229, and Mount Sinai Medical Center, New York, NY 10029.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Robert G. Hart, MD, Department of Neurology, University of Texas Health Science Center, 7703 Floyd Curl Drive, MC 7883, San Antonio, TX 78229-3900; e-mail, hartr@uthscsa.edu.

Current Author Addresses: Dr. Hart: Department of Neurology, University of Texas Health Science Center, 7703 Floyd Curl Drive, MC 7883, San Antonio, TX 78229-3900.

Dr. Halperin: The Zena and Michael A. Wiener Cardiovascular Institute, The Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Box 1030, Mount Sinai Medical Center, Fifth Avenue at 100th Street, New York, NY 10029-6574.

Ann Intern Med. 2009;151(5):355-356. doi:10.7326/0003-4819-151-5-200909010-00012
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Recommendations for identifying patients with nonvalvular atrial fibrillation who are at low, moderate, or high risk for thromboembolism have recently converged, advocating almost identical risk-stratification criteria (13). The widely promulgated CHADS2 scheme uses a system that assigns 1 point each for congestive heart failure, hypertension, age 75 years or older, and diabetes mellitus and 2 points for previous stroke or transient ischemic attack (4). Anticoagulation is generally not recommended for patients with atrial fibrillation who are at low risk for thromboembolism (CHADS2 score of 0; about 20% of patients with atrial fibrillation, who face an average stroke risk of 1% per year), but it is favored for patients at high risk (CHADS2 score ≥2; about 45% of patients with atrial fibrillation, whose stroke risk averages 4% to 5% per year) who can tolerate warfarin (13). For those at moderate risk (CHADS2 score of 1; about 35% of patients with atrial fibrillation, with an average stroke risk of 2% per year), either warfarin or aspirin is recommended (1), with warfarin being preferred in a prominent guideline (3). In this issue, Singer and colleagues (5) question the net clinical benefit of adjusted-dose warfarin for at least half of patients with atrial fibrillation, including the one third deemed to have moderate stroke risk (CHADS2 score of 1), who frequently receive warfarin now.

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