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Atrial fibrillation and anticoagulation: from randomised trials to practice
J J Caro1, P A Groome, K M Flegel
1Division of General Internal Medicine, Royal Victoria Hospital, McGill University, Montreal, Canada.
Lancet (London, England)
|May 29, 1993
Summary
Anticoagulants significantly reduce embolic risk in atrial fibrillation (AF). However, the risk of hemorrhage must be perceived as at least six times more detrimental than emboli to justify withholding anticoagulation.
Area of Science:
- Cardiology
- Clinical Pharmacology
- Evidence-Based Medicine
Background:
- Atrial fibrillation (AF) patients face a high risk of embolic events.
- Anticoagulant therapy is proven to reduce this embolic risk.
- Clinical guidelines require clear risk-benefit assessment for anticoagulation in AF.
Purpose of the Study:
- To develop a quantitative expression for the risk-benefit analysis of anticoagulation in AF.
- To determine the threshold at which hemorrhage risk outweighs embolic risk.
- To guide clinical decisions on anticoagulation for diverse AF patient populations.
Main Methods:
- Utilized data from randomized trials on anticoagulants in AF.
- Estimated risks of emboli and hemorrhage, and the impact of anticoagulants.
- Incorporated external data for patient groups not included in trials.
- Derived a ratio of detriment for hemorrhage versus emboli.
Main Results:
- Hemorrhage must be considered at least six times more detrimental than emboli to justify withholding anticoagulants in trial-like patients.
- Patients with lone AF or high bleeding risk (6x trial average) might warrant withholding anticoagulation if detriment is perceived equally.
Conclusions:
- A specific detriment ratio is crucial for clinical decision-making regarding anticoagulation in AF.
- Individual patient factors, particularly bleeding risk, significantly influence the anticoagulation decision.
- This framework aids in applying evidence-based anticoagulation strategies to real-world AF patient care.