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Intensity of Anticoagulation To Prevent Stroke in Patients with Atrial Fibrillation
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IN RESPONSE:
We agree that INRs of 2.0 or greater seem to provide optimal protection against embolic stroke and that the case–control study by Hylek and colleagues [1] demonstrates some protection against embolic stroke in the INR range of 1.6 to 2.0 Although it may be reasonable to target an INR of 2.0 within a range of 1.6 to 2.5 for some patients, we believe that several points must be considered before a less effective level of anticoagulation is accepted for elderly patients, who are also at highest risk for embolic stroke.
According to the results of a physician survey, many favor a less aggressive approach to anticoagulation for patients older than 75 years of age, perhaps because of a belief that all elderly patients have “special risks for bleeding” [2]. In the SPAF (Stroke Prevention in Atrial Fibrillation) III trial, elderly patients (mean age, 71 years) at high risk for stroke were treated with adjusted-dose warfarin (INR, 2.0 to 3.0) without excess hemorrhagic risk [3]. Moreover, major bleeding episodes occur most often at INRs greater than 4.0, well above the therapeutic range [4]. Therefore, we agree with Hylek and colleagues [1] that it may be preferable to put greater effort into tight control of the INR within the range of 2.0 to 3.0 than to accept less protection. In our view, the only patients for whom less anticoagulation may be sensible are those who have established special risks for bleeding.
John V.L. Sheffield, MD
Eric B. Larson, MD, MPH
University of Washington; Seattle, WA 98195
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
