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Canadian Journal of Cardiology

The Case Against Using Hypertension as the Only Criterion for Oral Anticoagulation in Atrial Fibrillation

  • Simon W. Rabkin
    Correspondence
    Corresponding author: Dr Simon W. Rabkin, Department of Medicine, Division of Cardiology, University of British Columbia, Level 9 2775 Laurel St, Vancouver, British Columbia V5Z 1M9, Canada. Tel.: +1-604-875-5847; fax: +1-604-875-5849.
    Affiliations
    Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
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  • Gordon Moe
    Affiliations
    Division of Cardiology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Published:March 25, 2015DOI:https://doi.org/10.1016/j.cjca.2015.03.022

      Abstract

      According to recent guidelines for atrial fibrillation (AF) management, the presence of hypertension warrants anticoagulation, often involving the use of newer oral anticoagulants (NOACs). To discuss this idea, we posited the case against this proposition. We note that the data on hypertension that formulated the most commonly used Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack (CHADS2) risk algorithm were not clearly defined and that there are insufficient data that hypertension in the presence of AF produces a meaningful incremental increase in stroke risk over and above the stroke risk increase for hypertension alone. Data exist that persons younger than 65 years of age with only 1 stroke risk factor such as hypertension, have a very small stroke risk. We further note that there are no quantitative data to allow clinicians to decide the level of blood pressure that meaningfully increases stroke risk in AF. Furthermore, there are insufficient data on the blood pressure level at which the risk of cerebral hemorrhage outweighs the risk of cardioembolic events. Clinical trials of NOACs in AF did not usually include hypertension as the only entry criteria. Another issue is the recent changes in the level of blood pressure for the diagnosis of hypertension based on home and ambulatory blood pressure measurement, which were not used to construct either stroke risk algorithms or entry criteria for NOAC clinical trials. These considerations highlight some of the complexities of using hypertension as a sole criterion for decision-making for anticoagulation in AF.

      Résumé

      Selon de récentes recommandations pour la gestion de la fibrillation auriculaire (FA), la présence d’une hypertension impose une anticoagulothérapie, impliquant souvent l'utilisation des nouveaux anticoagulants oraux (NACO). Pour examiner cette idée, nous avons posé la contre-argumentation suivante. Nous remarquons que les données sur l'hypertension qui ont aidé à formuler l’algorithme de stratification des risques le plus couramment utilisé, CHADS2 (l'insuffisance cardiaque congestive, l'hypertension, l'âge, le diabète, l'accident vasculaire cérébral/l'ischémie cérébrale transitoire), n’ont pas été clairement définies et qu’il y a trop peu de données démontrant qu’en cas de FA, l'hypertension produit une augmentation progressive significative du risque d'accident vasculaire cérébral (AVC) au-delà de l'augmentation du risque d'AVC en cas d’hypertension seule. Il existe des données montrant que les personnes de moins de 65 ans avec un seul facteur de risque d’AVC telle l'hypertension, ont un très faible risque d’AVC. Nous notons en outre qu'il n'y a pas de données quantitatives pour permettre aux cliniciens de décider du niveau de pression artérielle qui augmente significativement le risque d'AVC lors d’une FA. De plus, il n’existe pas suffisamment de données sur le niveau de pression artérielle pour lequel le risque d'hémorragie cérébrale dépasse le risque d'événements cardioemboliques. Les essais cliniques de NACO en cas de FA n’incluent habituellement pas l'hypertension comme seul critère d’inclusion. Un autre problème réside dans les changements récents du niveau de pression artérielle accepté pour le diagnostic d'hypertension sur la base de mesures de la pression artérielle faite à domicile ou en ambulatoire, et qui n’ont pas été utilisés pour élaborer soit des algorithmes de stratification du risque d'AVC ou des critères d’inclusion pour les essais cliniques de NACO. Ces éléments mettent en lumière certaines complexités dans l'utilisation de l'hypertension comme seul critère pour l'anticoagulothérapie en cas de FA.
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