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Vol. 65. Issue 4.
Pages 391-392 (April 2012)
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Vol. 65. Issue 4.
Pages 391-392 (April 2012)
DOI: 10.1016/j.rec.2012.01.004
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Comments on the Spanish Society of Cardiology Critical Review of the ESC 2010 Clinical Practice Guidelines on Atrial Fibrillation. Response
Comentarios al análisis crítico de la Sociedad Española de Cardiología de la guía de práctica clínica de fibrilación auricular 2010 de la ESC. Respuesta
Manuel Anguitaa,
Corresponding author

Corresponding author:
, Fernando Wornera
a Coordinadores del Grupo de Trabajo sobre Guías de Fibrilación Auricular, Comité de Guías de Práctica Clínica, Sociedad Española de Cardiología, Madrid, Spain
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To the Editor,

We have read with great interest the comments given by professors Lip and Camm regarding our recent critical review of the 2010 atrial fibrillation (AF) guidelines from the ESC,1 and we would like to thank them for their contributions to our article, which may clarify certain aspects of this subject that were left unresolved, in our opinion, by the guidelines. First of all, we would like to say that we do not refute that female sex, arterial hypertension, heart failure, and vascular disease can all increase the risk of embolism in patients with AF, but it is not clear whether this is the case only in certain situations or as a general rule. As the authors themselves and the guidelines of the ESC recognize, heart failure in the absence of left ventricular systolic dysfunction, controlled hypertension with no ventricular hypertrophy, a diagnosis of angina (with no other evidence of vascular disease), and female sex with no other risk factors for embolism and age <65 years may not constitute significant risk. In fact, in their letter Lip and Camm state that female sex as a lone risk factor, and therefore a CHA2DS2-VASc score of 1, may not require anticoagulant therapy. However, although the text of the ESC guidelines contains this same idea, the tables of recommendations (Tables 8 and 9) include anticoagulation for a score of 1 as a general rule, without specifying any details. We believe that this might confuse doctors reading the guidelines and we assume that it will be clarified in the updated version of the ESC guidelines on AF coming out in 2012. We can agree “in general terms” that the CHA2DS2-VASc scale can identify additional subgroups not covered by the CHADS2 scale and better categorizes patients with a low (0) and high (2 or more) embolic risk score. However, in addition to the fact that not all studies agree that a CHA2DS2-VASc score of 1 reflects a greater risk of embolism,2 the greatest caution against applying this standard is the total lack of evidence that anticoagulation therapy in patients with a CHADS2 ≤2 and a low CHA2DS2-VASc (1-2) score provides a significant net clinical benefit if we assess the hypothetical decrease in embolic events versus the possible increase in hemorrhagic events. Furthermore, this analysis does not address the economic cost-benefit, especially if the new oral anticoagulants are prescribed.

With regard to the recommendations on dronedarone, although the guidelines do not explicitly recommend its use in patients with permanent AF, this is considered reasonable therapy for long-term control of heart rate (IIA, evidence level B), which could lead to confusion. The publication of the PALLAS study3 and the recent recommendations from medications agencies, compiled in our article,1 have resolved these questions and clarified, at least for the time being, the role of dronedarone in AF by confirming that the importance given by the guidelines to this drug was hasty and unprecedented in the history of ESC guidelines.


Corresponding author:

Anguita M, Worner F, Domenech P, Marín F, Ortigosa J, Pérez-Villacastín J, et al..
Nuevas evidencias, nuevas controversias: análisis crítico de la guía de práctica clínica sobre fibrilación auricular 2010 de la Sociedad Europea de Cardiología..
Rev Esp Cardiol. , 65 (2012), pp. 7-13
Ruiz-Ortiz M, Romo E, Mesa D, Delgado M, López-Ibáñez C, Suárez de Lezo J..
Efectividad de la anticoagulación oral en la fibrilación auricular no valvular según el score CHA 2DS 2-VASc en pacientes con riesgo embólico bajo-intermedio..
Rev Esp Cardiol. , 65 (2012), pp. 383-384
Connolly SJ, Camm AJ, Halperin JL, Joyner C, Alings M, Amerena J, et al, for the PALLAS Investigators..
Dronedarone in high-risk permanente atrial fibrillation..
N Engl J Med. , 365 (2011), pp. 2268-2276
Revista Española de Cardiología (English Edition)

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