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It is perhaps unfortunate timing, but Sudlow et al's assertion that
the treatment effect of warfarin for patients with non-rheumatic atrial
fibrillation is known, is refuted in the same edition of the BMJ. Hardman
and Cowie make the point that the treatment effect of around 68% risk
reduction for stroke is derived from highly selected populations and that
it would be dangerous to assume this to be the case in a community
population. Similarly, the prevalence of atrial fibrillation is not
established in the UK. I would agree that risk assessment and
stratification is an important issue, however this must be seen in the
context of dealing with uncertainty. We cannot make rational decisions on
risk assessment in the over 75 population as even the primary data is
inconclusive in this age group.
We have the opportunity, given the increased interest in this area to
finally deliver the necessary answers to these important questions. It
will be necessary however to formally evaluate screening strategies to
identify atrial fibrillation as well as defining the treatment effect in
an unselected, community derived population before one could be as
confident as Sudlow and colleagues of the overall benefit of warfarin.
Competing interests:
No competing interests
28 January 1999
D A Fitzmaurice
Senior Lecturer
Department of Primary Care and General Practice, The University of Birmingham, B15 2TT
The answer is in the BMJ
It is perhaps unfortunate timing, but Sudlow et al's assertion that
the treatment effect of warfarin for patients with non-rheumatic atrial
fibrillation is known, is refuted in the same edition of the BMJ. Hardman
and Cowie make the point that the treatment effect of around 68% risk
reduction for stroke is derived from highly selected populations and that
it would be dangerous to assume this to be the case in a community
population. Similarly, the prevalence of atrial fibrillation is not
established in the UK. I would agree that risk assessment and
stratification is an important issue, however this must be seen in the
context of dealing with uncertainty. We cannot make rational decisions on
risk assessment in the over 75 population as even the primary data is
inconclusive in this age group.
We have the opportunity, given the increased interest in this area to
finally deliver the necessary answers to these important questions. It
will be necessary however to formally evaluate screening strategies to
identify atrial fibrillation as well as defining the treatment effect in
an unselected, community derived population before one could be as
confident as Sudlow and colleagues of the overall benefit of warfarin.
Competing interests: No competing interests