"Diagnosis Creep": Are Some AF Patients Overtreated (with Anti-coagulants)?

[mjames1]

Interesting article in Medscape. You should be able to get full copy for free by just registering.

medscape.com/viewarticle/99...

Of note is that Dr. Lip -- one of the developers of the CHADS risk score -- talks about its limitations:

"...These risks scores are by design simplifications, and only have modest predictive value for identifying patients at high risk of stroke. You can always improve on clinical risk scores by adding in other variables," he said. "There are some risk scores in AF with 26 variables. But the practical application of these more complex scores can be difficult in clinical practice. These risks scores are meant to be simple so that they can be used by busy clinicians in the outpatient clinic or on a ward round. It is not easy to input 26 different variables."

Dr. Turakhia adds to this : " it is imperative to look at the bigger picture when identifying AF patients for anticoagulation. "We have to be careful not to take things at face value. It is more important than ever to use clinical judgment to avoid overtreatment in borderline situations," he concluded.

In other words, while the CHADS risk score is a good starting point, it doesn't trump the decision of a good clinician who may take into account a number of other factors.

Jim

[Autumn_Leaves]

There seems to be a lot of emphasis on BP in that article, and whether hypertension begins at 130/85 or 140/90. There is the bleed risk of course, and I have wondered whether it would be more helpful to have clotting studies done when considering the decision. There’s also the question of how frequently someone is in AF. If someone was in permanent AF would their risk be higher than someone who has one episode of AF lasting 20 minutes once or twice a year? The more we can quantify various parameters with more sophisticated testing, the more complicated the picture becomes. I get that everyone *wants* to be low risk, but it doesn’t necessarily follow that the ARE low risk. That’s another issue really, there are plenty of people in denial who want to believe they can fix themselves with turmeric capsules or pomegranate juice. Our decisions are always on us, ultimately.

[Threecats in reply to Autumn_Leaves]

You raise some interesting points there, Autumn. I agree with you that clotting studies, particularly for those at low/medium risk would be a more useful indicator as to whether ACs were needed. I have also wondered whether the switching between AFib and NSR would be more likely to increase stroke risk than being in a steady state of constant AF. My thinking being that the heart beats more forcefully when in NSR and so could perhaps be more likely to dislodge any clot that might have formed in the LAA during an episode. As always in this AF game, so many imponderables!

[Gumbie_Cat in reply to Autumn_Leaves]

I was very relieved to be prescribed anticoagulants, because I personally see myself as high risk. Though the measures like BP etc only just scored me at 2, due to sex and age.

Extra relieved now that I’m in it permanently - though I had waited until early last year (age 67) to get diagnosed. (Thanks to my expensive watch purchase.)

I do get that screening could lead to people being medicated unnecessarily, but these things can definitely work both ways. Two older sisters with strokes at 64 and 65, due to undiagnosed AFib, so I was worried about it. Especially after a retinal vein occlusion, which my optometrist indicated was a warning sign. I was still just under 65, and was told that even if there was some AFib, I didn’t have other risk factors. I distinctly remember getting upset and saying that I felt like a ticking time bomb. I guess that’s the trouble with algorithms, some things just don’t feed into them.

[CDreamer]

I read that, some good points made and certainly food for thought for those with hypertension.

Personally I have hypotension which doesn’t rate as a risk factor and I’ve not understood why as it tends to make us more susceptible to clots from blood pooling in legs.

Constantly changing parameters brings uncertainty which in turn raises anxiety for sufferers and I’ve never understood why anxiety is not considered a risk factor either and no just for hypertension and AF but for all diseases and but especially hypertension and AF. There are still so many variables to be quantified.

I just had an excellent review for osteoporosis with a very sensible doctor whose No1 risk for assessment was frailty - not chronicalogical age but biological age and frailty. Nothing beats taking full family and clinical history and honing clinical judgement.

We all have response ability for our own health but many seem to prefer to be told what to do.

[secondtry]

Totally agree a good clinician assessment in partnership with the patient has no substitute.

A couple of points, which may or may not be relevant is to check out what the European Cardiology body advises as a comparison to the UK equivalent.

I also take some comfort in my decision to postpone taking ACs on the basis I have always been very sporty in my life and therefore the heart muscle should still be pretty good at ejecting blood before a clot can start. I emphasise this is not a medical but personal opinion and only relevant (if at all) if like me AF episodes are short (less than an hour) and very rare (2 in the last 10yrs). No doubt those with more medical knowledge will now shatter my allusion 😖🫣😀.

[Chinkoflight in reply to secondtry]

I had the severe stroke first, paroxysmal AFib found 14 months later. No other cardiovascular issues! I think your understanding of clot formation in the atrium is novel! I'm on DOAC now and glad of it. I take managing my health very seriously now and my cardiovascular system has moved from okay for my age to one of a younger person! Result. I'm still at risk of another stroke but I'm working on reducing the odds!

[Jajarunner]

Thanks Jim. Always find your posts informative. I'd love to get off the 'blood thinners' as I have a bleeding disorder which they make worse....

[MarkS]

I thought I was very low risk - CHADS2VASC zero, very fit playing field hockey, no smoking or excessive drinking and I still had a TIA in my 50's. On warfarin ever since plus ablation and no further problems. I understand that the shape of the Left Atrial Appendage is very significant but is difficult to determine without an MRI.

[dedeottie]

same here. I think left atrial appendage shape absolutely must surely be a factor but as you say, it would take an MRI to tell, but that would be a way of deciding who had anticoagulants even if chads score was low. X