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Ron Pisters, MD; Robby Nieuwlaat, PhD; Deirdre A. Lane, PhD; Harry J. G. M. Crijns, MD; Gregory Y. H. Lip, MD; for the ATRIA Study Investigators
Author and Funding Information

From the Department of Cardiology, Maastricht University Medical Centre (Drs Pisters, Nieuwlaat, and Crijns); and the University of Birmingham Centre for Cardiovascular Sciences, City Hospital (Drs Lane and Lip).

Correspondence to: Gregory Y. H. Lip, MD, University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham B18 7QH, England; e-mail: g.y.h.lip@bham.ac.uk


Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Pisters has consulting fees from Bayer and Boehringer Ingelheim and lecture fees from Boehringer Ingelheim. Dr Lane is the recipient of an investigator-initiated educational grant from Bayer Healthcare and has received sponsorship to attend the European Society of Cardiology Congress 2009 from AstraZeneca. Dr Crijns has received consulting fees from Boehringer Ingelheim, Sanofi-Aventis, and AstraZeneca; grant support from St. Jude Medical, Boston Scientific, Boehringer Ingelheim, Sanofi-Aventis, Medapharma, and Merck; and honoraria from Medtronic, Sanofi-Aventis, Medapharma, Merck, Boehringer Ingelheim, and Biosense Webster. Dr Lip has served as a consultant for Bayer, Astellas, Merck, AstraZeneca, Sanofi-Aventis, Aryx, Portola, Biotronic, and Boehringher Ingelheim, and has been on the speakers bureau for Bayer, Boehringher Ingelheim, and Sanofi-Aventis. Dr Nieuwlaat has reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;139(5):1249-1250. doi:10.1378/chest.10-3237
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To the Editor:

We thank Drs Vázquez and Sánchez-Perales for their interest in our recent article in CHEST (November 2010).1 We would like to emphasize our mutual agreement on the importance of chronic kidney failure (defined as the presence of chronic dialysis or renal transplantation or serum creatinine ≥200 μmol/L) as a thromboembolic risk factor, as was highlighted in the article by Go et al2 on the importance of decreased glomerular filtration rate and proteinuria as risk factors for stroke.

However, patients with chronic kidney failure represent a difficult treatment problem. Not only are these patients at high risk of thromboembolism, but they are also at high risk of bleeding, myocardial infarction, vascular events, and all-cause mortality.3 That the Euro Heart Survey on atrial fibrillation (AF) did highlight the absence of definitive evidence on chronic kidney failure or proteinuria is a limitation, as we did not have information on proteinuria in our survey. Nonetheless, patients with severe chronic kidney failure have not been adequately studied in clinical trials of stroke prevention in AF, and our proposal of using the HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly [>65 years], drugs/alcohol concomitantly) score was meant to provide a simple, user-friendly score for use in everyday clinical practice that would be applicable for the majority of patients with AF. Indeed, one could informally apply an unwritten rule for guideline writing: that any recommendations need to be applicable for >80% of the time, in >80% of the patient population.

Drs Vasquez and Sánchez-Perales challenge our discouragement of the use of oral anticoagulation if the HAS-BLED score outweighs the CHADS2 (congestive heart failure, hypertension, age >75 years, diabetes mellitus, previous stroke/transient ischemic attack [doubled]) score.1 Balancing the risk of stroke and bleeding solely based on this simplistic subtraction is tricky and fails to take into account significant (and important) differences in morbidity, mortality, and associated costs within the different types of major bleeding and compared with AF-related ischemic strokes. Indeed, a high HAS-BLED score is indicative of the need for caution and/or regular review of patients following the initiation of antithrombotic therapy, rather than the complete nonuse of oral anticoagulation.4

Despite the awareness of the above-mentioned shortcomings of our proposed “rule,” we strongly believe its use is justified. Compared with a scenario in which no practical guidance on balancing stroke and bleeding risks in patients with AF is available, large numbers of patients are automatically deemed unsuitable for oral anticoagulation. Given that poor guideline adherence has a significant impact on adverse outcomes, undertreatment can be reduced by applying decision rules, at the cost of a few cases in which oral anticoagulation may be withheld.1

With regard to the scenario illustrated by Vázquez and Sánchez-Perales of a 75-year-old man with renal failure and hypertension, a history of hypertension is less of a risk than uncontrolled hypertension, in relation to bleeding.1 With the age of 75 and the presence of renal failure scoring, the patient’s HAS-BLED score is 2. As his CHADS2 score is also 2, application of our rule in this specific case would actually favor the use of oral anticoagulation. Even if a particular patient has a HAS-BLED score of ≥3, this is an “alarm bell” for caution and a signal that correctable bleeding risk factors should be treated (eg, cessation of concomitant aspirin use with oral anticoagulation, control of BP, labile international normalized ratios, etc) to lower the HAS-BLED score.4

Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJGM, Lip GYH. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest. 2010;1385:1093-1100. [CrossRef] [PubMed]
 
Go AS, Fang MC, Udaltsova N, et al; for the ATRIA Study Investigators for the ATRIA Study Investigators Impact of proteinuria and glomerular filtration rate on risk of thromboembolism in atrial fibrillation: the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) study. Circulation. 2009;11910:1363-1369. [CrossRef] [PubMed]
 
Lip GYH. Chronic renal disease and stroke in atrial fibrillation: balancing the prevention of thromboembolism and bleeding risk. Europace. 2011;132:145-148. [CrossRef] [PubMed]
 
Camm AJ, Kirchhof P, Lip GY, et al; European Heart Rhythm Association European Heart Rhythm Association European Association for Cardio-Thoracic Surgery European Association for Cardio-Thoracic Surgery ESC Committee for Practice Guidelines ESC Committee for Practice Guidelines Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Europace. 2010;1210:1360-1420. [CrossRef] [PubMed]
 

Figures

Tables

References

Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJGM, Lip GYH. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest. 2010;1385:1093-1100. [CrossRef] [PubMed]
 
Go AS, Fang MC, Udaltsova N, et al; for the ATRIA Study Investigators for the ATRIA Study Investigators Impact of proteinuria and glomerular filtration rate on risk of thromboembolism in atrial fibrillation: the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) study. Circulation. 2009;11910:1363-1369. [CrossRef] [PubMed]
 
Lip GYH. Chronic renal disease and stroke in atrial fibrillation: balancing the prevention of thromboembolism and bleeding risk. Europace. 2011;132:145-148. [CrossRef] [PubMed]
 
Camm AJ, Kirchhof P, Lip GY, et al; European Heart Rhythm Association European Heart Rhythm Association European Association for Cardio-Thoracic Surgery European Association for Cardio-Thoracic Surgery ESC Committee for Practice Guidelines ESC Committee for Practice Guidelines Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Europace. 2010;1210:1360-1420. [CrossRef] [PubMed]
 
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