The case against using hypertension as the only criterion for oral anticoagulation in atrial fibrillation

According to recent guidelines for atrial fibrillation (AF) management, the presence of hypertension warrants anticoagulation, often involving the use of newer oral anticoagulants (NOACs). To discuss this idea, we posited the case against this proposition. We note that the data on hypertension that formulated the most commonly used Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack (CHADS2) risk algorithm were not clearly defined and that there are insufficient data that hypertension in the presence of AF produces a meaningful incremental increase in stroke risk over and above the stroke risk increase for hypertension alone. Data exist that persons younger than 65 years of age with only 1 stroke risk factor such as hypertension, have a very small stroke risk. We further note that there are no quantitative data to allow clinicians to decide the level of blood pressure that meaningfully increases stroke risk in AF. Furthermore, there are insufficient data on the blood pressure level at which the risk of cerebral hemorrhage outweighs the risk of cardioembolic events. Clinical trials of NOACs in AF did not usually include hypertension as the only entry criteria. Another issue is the recent changes in the level of blood pressure for the diagnosis of hypertension based on home and ambulatory blood pressure measurement, which were not used to construct either stroke risk algorithms or entry criteria for NOAC clinical trials. These considerations highlight some of the complexities of using hypertension as a sole criterion for decision-making for anticoagulation in AF.