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Antithrombotic Therapy To Prevent Stroke in Patients with Atrial Fibrillation
- Robert G. Hart, MD; and
- Lesly A. Pearce, MS
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IN RESPONSE:
Thanks to Dr. Singer for pointing out a misleading heading in Table 2 of our meta-analysis: “Control group” was inadvertently changed to “placebo group” in the process of revision.
Dr. Singer's lack of enthusiasm for aspirin use in atrial fibrillation is long-standing and often voiced (1, 2). His current concerns appear based on post hoc exploratory subgroup analyses of SPAF I, which are not relevant to our meta-analysis. To date, all six randomized trials (five of them double-blind) have shown trends toward reduction in stroke with aspirin use in patients with atrial fibrillation (see the Figure in our meta-analysis). Furthermore, randomized trials comparing warfarin with aspirin have consistently shown a smaller magnitude of stroke reduction than seen in trials comparing warfarin with control or placebo. In short, it seems overwhelmingly likely that aspirin provides some protection against stroke in atrial fibrillation, but the efficacy is clearly much less than that provided by adjusted-dose warfarin, particularly when considering disabling cardioembolic strokes.
It is also clear that many patients with atrial fibrillation who are treated with aspirin have low rates of stroke (whether in part due to or, per Dr. Singer, despite aspirin use) and would not benefit substantially from alternative treatment with warfarin (3-5). The salient clinical issue for the next millennium is not whether aspirin works in atrial fibrillation (it does, but only a little) but rather how to reliably identify individual patients with atrial fibrillation who have relatively low risks for stroke during aspirin therapy and who might not choose anticoagulation once the modest benefits, risks, and disutility are made clear (5).
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
