To the Editor: Atrial fibrillation (AF) is a common problem in the Emergency Department. Rheumatic valvular disease used to be the most common cause of AF in Saudi Arabia; however, hypertension and ischemic heart disease are progressively becoming an important cause.1 Arterial thromboembolism is the most serious complication of AF, especially ischemic strokes.2 Hence it is essential to identify which AF patient is prone to this complication and to make the decision to recommend aspirin or warfarin, whichever is appropriate. CHADS2 score is the most widely used clinical model for assessment of stroke risk for patients with nonvalvular AF. According to the CHADS2 risk scores, patients were divided into low (CHADS2=0), intermediate (CHADS2=1) and high-risk (CHADS2≥2) groups. However, the therapy has to be weighed against the risk of major bleeding.3
We conducted a prospective observational pilot study at the King Abdulaziz Medical City, National Guard Hospital, Jeddah, a tertiary referral hospital, over a period of 6 months—from April to October 2010, to determine the risk profile of patients admitted with AF and to ascertain reasons for withholding oral anticoagulant treatment in eligible patients. A total of 36 AF patients were identified, 15 with paroxysmal AF and 21 with persistent AF. Both groups were risk-stratified according to CHADS2 scores; and the selected treatment, anticoagulant versus antiplatelet, on hospital admission was correlated to current guidelines.
Hypertension was the most comorbid disease found in both groups, constituting 80% in paroxysmal AF and 81% in persistent AF patients. Diabetes mellitus was the second most comorbid condition, with 53.3% in paroxysmal AF and 47.6% in persistent AF patients. This is in contrast to rheumatic fever, which was associated with persistent AF in 9.5% of the patients (Table 1). Two (5.6%) patients were classified as low-risk patients; 4 (11.1%), as intermediate-risk patients; and 30 (83.3%), as high-risk patients. Five (13.9%) of those at high risk were not on anticoagulant therapy as per the guideline, because of the presence of history of bleeding in 2 patients, 1 in each group; and 1 patient having psychiatric problem; and 2, presumably, being drug non-compliant, as seen in Table 2. Further studies are warranted due to the small sample size of our study.
Table 1.
Characteristics of patients with paroxysmal and persistent atrial fibrillation
Table 2.
CHADS 2 score and modalities of treatment among AF patients
We conclude that hypertension and diabetes mellitus are common comorbid diseases associated with AF, and rheumatic fever was the least common cause in Saudi patients with AF. There is room for improvement in tailoring anticoagulation to thromboembolic risk.
REFERENCES
- 1.Shatoor AS, Ahmed ME, Said MA, Shabbir K, Cheema A, Kardash MO. Patterns of atrial fibrillation at a regional hospital in Saudi Arabia. Ethn Dis. 1998;8:360–6. [PubMed] [Google Scholar]
- 2.Go AS, Hylek EM, Chang Y, Phillips KA, Henault LE, Capra AM, et al. Anticoagulation therapy for stroke prevention in atrial fibrillation: How well do randomized trials translate into clinical practice? JAMA. 2003;290:2685–92. doi: 10.1001/jama.290.20.2685. [DOI] [PubMed] [Google Scholar]
- 3.Singer DE, Albers GW, Dalen JE, Fang MC, Go AS, Halperin JL, et al. American College of Chest Physicians.Antithrombotic therapy in atrial fibrillation: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) Chest. 2008;133:546S–92. doi: 10.1378/chest.08-0678. [DOI] [PubMed] [Google Scholar]