Atrial fibrillation management: Issues of concern

To the Editor: I read with interest the article by Drs. Callahan and Baranowski¹ in your April 2011 issue about managing newly diagnosed atrial fibrillation. I believe several issues merit further discussion.

First of all, as mentioned in the article, pulmonary vein isolation, or radiofrequency catheter ablation of the left atrium, can cure paroxysmal atrial fibrillation. Callahan and Baranowski described the optimal indication for this procedure, but they failed to mention the potential adverse effects, that is, esophageal ulcer and atrio-esophageal fistula.² Owing to the proximity of the esophagus and the accompanying vagus nerve to the posterior wall of the left atrium, it is estimated that 47% of patients develop thermal mucosal injury and 18% develop esophageal ulcer after ablation, while 0.5% develop atrio-esophageal fistula.³ Gastric hypomotility and pyloric spasm are reported as well. It would therefore be prudent to inform patients of such risks if a persistently symptomatic young patient demands this procedure, since the damage might be long-lasting.

In addition, in deciding on long-term anticoagulation for patients with atrial fibrillation, the CHADS₂ score is often utilized (1 point each for congestive heart failure, hypertension, age 75 or older, and diabetes mellitus; 2 points for prior stroke or transient ischemic attack). Although it is validated and widely applicable, the CHADS₂ score carries the disadvantages of oversimplification and of overclassifying atrial fibrillation patients into the intermediate-risk category.⁴ Lip et al,⁵ in a seminal article surveying a large group of patients who had nonvalvular atrial fibrillation, proposed using a new and also simple risk stratification scheme, the 2009 Birmingham scheme. This scheme uses the acronym CHA₂DS₂-VASc and differs from the CHADS₂ score in that patients age 75 or older get 2 points, those age 65 to 74 get 1 point, those with vascular disease get 1 point, and women get 1 point. They show that this new scheme fares marginally better than the original CHADS₂ score, with fewer patients wrongly assigned to the intermediate-risk category. That means a lower percentage of patients will receive unnecessary anticoagulation and suffer from unneeded anguish. Subsequent studies also prove that this newer scoring index possesses higher sensitivity and predicts thromboembolic events more accurately than the CHADS₂ score. Thus, I believe this should also be factored into the decision process when initiating warfarin in atrial fibrillation patients, especially in light of the fact that scanty evidence exists for the use of newer anticoagulants based on the CHADS₂ score.

To the Editor: I read with interest the article by Drs. Callahan and Baranowski¹ in your April 2011 issue about managing newly diagnosed atrial fibrillation. I believe several issues merit further discussion.

First of all, as mentioned in the article, pulmonary vein isolation, or radiofrequency catheter ablation of the left atrium, can cure paroxysmal atrial fibrillation. Callahan and Baranowski described the optimal indication for this procedure, but they failed to mention the potential adverse effects, that is, esophageal ulcer and atrio-esophageal fistula.² Owing to the proximity of the esophagus and the accompanying vagus nerve to the posterior wall of the left atrium, it is estimated that 47% of patients develop thermal mucosal injury and 18% develop esophageal ulcer after ablation, while 0.5% develop atrio-esophageal fistula.³ Gastric hypomotility and pyloric spasm are reported as well. It would therefore be prudent to inform patients of such risks if a persistently symptomatic young patient demands this procedure, since the damage might be long-lasting.

In addition, in deciding on long-term anticoagulation for patients with atrial fibrillation, the CHADS₂ score is often utilized (1 point each for congestive heart failure, hypertension, age 75 or older, and diabetes mellitus; 2 points for prior stroke or transient ischemic attack). Although it is validated and widely applicable, the CHADS₂ score carries the disadvantages of oversimplification and of overclassifying atrial fibrillation patients into the intermediate-risk category.⁴ Lip et al,⁵ in a seminal article surveying a large group of patients who had nonvalvular atrial fibrillation, proposed using a new and also simple risk stratification scheme, the 2009 Birmingham scheme. This scheme uses the acronym CHA₂DS₂-VASc and differs from the CHADS₂ score in that patients age 75 or older get 2 points, those age 65 to 74 get 1 point, those with vascular disease get 1 point, and women get 1 point. They show that this new scheme fares marginally better than the original CHADS₂ score, with fewer patients wrongly assigned to the intermediate-risk category. That means a lower percentage of patients will receive unnecessary anticoagulation and suffer from unneeded anguish. Subsequent studies also prove that this newer scoring index possesses higher sensitivity and predicts thromboembolic events more accurately than the CHADS₂ score. Thus, I believe this should also be factored into the decision process when initiating warfarin in atrial fibrillation patients, especially in light of the fact that scanty evidence exists for the use of newer anticoagulants based on the CHADS₂ score.

To the Editor: I read with interest the article by Drs. Callahan and Baranowski¹ in your April 2011 issue about managing newly diagnosed atrial fibrillation. I believe several issues merit further discussion.

First of all, as mentioned in the article, pulmonary vein isolation, or radiofrequency catheter ablation of the left atrium, can cure paroxysmal atrial fibrillation. Callahan and Baranowski described the optimal indication for this procedure, but they failed to mention the potential adverse effects, that is, esophageal ulcer and atrio-esophageal fistula.² Owing to the proximity of the esophagus and the accompanying vagus nerve to the posterior wall of the left atrium, it is estimated that 47% of patients develop thermal mucosal injury and 18% develop esophageal ulcer after ablation, while 0.5% develop atrio-esophageal fistula.³ Gastric hypomotility and pyloric spasm are reported as well. It would therefore be prudent to inform patients of such risks if a persistently symptomatic young patient demands this procedure, since the damage might be long-lasting.

In addition, in deciding on long-term anticoagulation for patients with atrial fibrillation, the CHADS₂ score is often utilized (1 point each for congestive heart failure, hypertension, age 75 or older, and diabetes mellitus; 2 points for prior stroke or transient ischemic attack). Although it is validated and widely applicable, the CHADS₂ score carries the disadvantages of oversimplification and of overclassifying atrial fibrillation patients into the intermediate-risk category.⁴ Lip et al,⁵ in a seminal article surveying a large group of patients who had nonvalvular atrial fibrillation, proposed using a new and also simple risk stratification scheme, the 2009 Birmingham scheme. This scheme uses the acronym CHA₂DS₂-VASc and differs from the CHADS₂ score in that patients age 75 or older get 2 points, those age 65 to 74 get 1 point, those with vascular disease get 1 point, and women get 1 point. They show that this new scheme fares marginally better than the original CHADS₂ score, with fewer patients wrongly assigned to the intermediate-risk category. That means a lower percentage of patients will receive unnecessary anticoagulation and suffer from unneeded anguish. Subsequent studies also prove that this newer scoring index possesses higher sensitivity and predicts thromboembolic events more accurately than the CHADS₂ score. Thus, I believe this should also be factored into the decision process when initiating warfarin in atrial fibrillation patients, especially in light of the fact that scanty evidence exists for the use of newer anticoagulants based on the CHADS₂ score.