Atrial fibrillation and mortality: the impact of antithrombotic therapy

Abstract

This editorial refers to ‘Mortality predictors and effects of antithrombotic therapies in atrial fibrillation: insights from ACTIVE-W’[†][1], by R. De Caterina et al. , on page 2133 All of the current guidelines on antithrombotic therapy for atrial fibrillation (AF) emphasize the prevention of stroke and thromboembolism as the primary goal of such treatment, and existing recommendations for antithrombotic therapy are based on an individual patient's risk of stroke. These guidelines have been formulated from the numerous clinical trials of antithrombotic therapy in patients with AF conducted over the last 20 years, where the primary endpoint has been stroke or a composite endpoint of stroke/thromboembolism, vascular events, and death. More recently, clinical trials of antithrombotic therapy in patients with AF have rightly included bleeding events as part of the composite primary endpoint, as treatment decisions should be based upon net clinical benefit. A meta-analysis1 of the 12 trials comparing dose-adjusted warfarin with antiplatelet therapy alone, including the largest trial to date, the Atrial Fibrillation Clopidogrel Trial with Irbesartan for Prevention of Vascular Events (ACTIVE-W) trial,2 revealed a 37% reduction [95% confidence interval (CI) 23–48%] in all strokes associated with dose-adjusted warfarin1 but did not demonstrate a significant mortality benefit of warfarin over aspirin [relative risk reduction (RRR) 9%; 95% CI –19 to 30%]; … *Corresponding author. Tel: +44 121 507 5080, Fax: +44 121 507 5907, Email: deirdre.lane{at}swbh.nhs.uk [1]: #fn-2