Clinical Question: Which patients w...

Clinical Question: Which patients with atrial fibrillation would benefit from anti-coagulation?

Setting: Various (meta-analysis)

consideration Design: Decision rule (validation)

Synopsis: Investigators ordealed the ability of five clinical decision masterys to accurately identify low-risk patients with atrial fibrillation who do not ne anticoagulation and high-risk patients who do. In this thought the validation population consisted of puddleed data from 2,580 patients in the aspirin arm (75 to 325 mg daily) of six randomized con-troll trials. The mean age of participants was 72 years, 37 percent were women 46 percent had hypertension, and 22 percent had a previous calamity or transient ischemic attack. All five dominations were able to divide patients into low- moderate-, and high-risk assemblages However, the number of patients in the low-risk clump varied from 175 to 983 while the number in the high-risk arrange ranged from 223 to 1543

Identifying a greater percentage of patients in the low- and high-risk form into groupss is better than having too many patients in the intermediate dispose (in which no definitive advice can be given). The pat Prevention in Atrial Fibrillation domination performed well. According to this empire patients with any of the following characteristics were considered to be at high risk: systolic offspring pressure greater than 160 mm Hg previous ischemia, new heart failure, or left ventricular ejection fraction les than or equal to 25 percent Women older than 75 years also implacable into the high-risk category.

Patients who were at high risk had a 36 percent risk of attack (95 percent confidence interval [CI], 27 to 47; n = 884) Patients who had none of the high-risk factors moreover had hypertension were considered to be at moderate risk and had a 27 percent risk of affliction (95 percent CI, 1.8 to 40; n = 462) Finally, low-risk patients (i.e., anyone who was not at moderate or high risk) had a 11 percent risk of visitation (95 percent CI, 0.7 to 18; n = 668)

The authors like the CHADS2 government named for the elements in the score (Congestive heart failure, Hypertension, Age, Diabetes, and previous misfortune or transient ischemic attack). However, this score placed the majority of patients in the intermediate dispose which is less helpful for clinical decision making.

Bottom Line: Clinical decision methods especially the well-validated Stroke Prevention in Atrial Fibrillation domination can help identify which clusters of patients with atrial fibrillation are likely or unlikely to benefit from anticoagulation. (Level of Evidence: 1a)

cogitation Reference: Gage BF, et al. Selecting patients with atrial fibrillation for anticoagulation: attack risk stratification in patients taking aspirin. Circulation October 19 2004;110:2287-92

Used with permission from Ebell M Clinical decision dominations accurately predict stroke risk in AF. Accessed online March 1 2005 at: http://www.InfoPOEMs.com.

COPYRIGHT 2005 American Academy of Family Physicians

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