Anticoagulation therapy for patients with atrial fibrillation

Robert Hart makes several astute observations in his recent letter¹ and in general I agree that warfarin therapy is not well used in atrial fibrillation; it is overused among low-risk patients and underused among high-risk patients. Perhaps the problem is more with the treatment itself than with the physician using it. Adjusted-dose warfarin treatment is a complex therapy that requires assiduous and ongoing monitoring to achieve good results, with a narrow therapeutic window. It ties patients to the medical system, interferes with travel and complicates use of alcohol and of many common medications. Although a decade has passed since we learned that warfarin is beneficial in atrial fibrillation, many patients with atrial fibrillation who are at a high risk for stroke are not receiving adequate prophylaxis. With new antithrombin agents on the horizon and more effective antiplatelet agents (alone and in combination) already available, perhaps our efforts should be directed toward discovering effective antithrombotic control for atrial fibrillation that is safer than warfarin therapy and easier to manage.

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Stuart J. Connolly
Professor of Medicine McMaster University Hamilton, Ont