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Most therapeutic interventions quickly show their real benefits in certain patient groups and absence of benefits or even harm in others. That leaves a grey zone in between that gives rise to opinions and often heated discussions on where to draw the line between indication or not. For conditions that affect large groups of patients with chronic illnesses, the drawing line may be different in primary versus secondary care settings. One of such highly disputed grey zones is on the threshold to start oral anticoagulant therapy in patients with atrial fibrillation (AF). Only scientific data can help to visualise the division line more clearly, to narrow down the grey area and to abate opinionated discussions. That is exactly what the authors of an article in this issue have tried to do.1 They report on the net clinical benefit of anticoagulation with vitamin-K antagonists (VKAs) in real-world patients with AF, both in primary and secondary care. But do their data bring us closer to the answer and to a silencing of discussions?
The strength of the study lies in the fact that treatment and outcome information of a large cohort of patients (n=70 206), both from primary and secondary care (42.1% respectively 57.9% of the cohort), was included through linking of four separate electronic databases spanning both settings of care. Median follow-up was 2.2 years. The authors found that the stroke risk in the CHA2DS2-VASc groups from 0 to 4 was significantly lower compared with the rates cited earlier.2 This may be explained by less underclassification of stroke risk through the combined database linkage. The lower stroke rates also may explain why in the groups with only one additional risk factor (ie, men with a CHA2DS2-VASc score of 1 or women with a …
Competing interests The author reports receiving consulting fees as member of the scientific advisory boards for Boehringer-Ingelheim, Bayer, Bristol-Myers Squibb-Pfizer, Daiichi-Sankyo and Cardiome and reports receiving lecture fees from these same companies.
Provenance and peer review Commissioned; internally peer reviewed.