4 ms·

Perhaps it would be more accurate to say "we might catch more AF early, and anticoagulating those people might reduce their risk of debilitating stroke more tha

Perhaps it would be more accurate to say "we might catch more AF early, and anticoagulating those people might reduce their risk of debilitating stroke more than we increase their risk of lethal gi bleed or head bleed"? The issue is whether the af you find through this kind of screening is associated with the same risk of stroke as conventionally diagnosed af - if not, their risk reduction from anticoagulation might not justify the bleeding risk from anticoagulating them. The linked article suggests it might be "unethical" to even do a trial of anticoagulation vs control in af detected by such screening. That seems like a dangerous position for them to take, particularly coming from a group that is largely funded by the drug companies who sell expensive anticoagulation medication. I would encourage readers to jump to the "sources of funding" and "disclosures" section of the linked review article to see just how many of the authors receive money from the drug companies. None of that is a criticism of the authors of the UCSF study, this kind of technology is certainly an area worth exploring. I would just be very wary of the push by drug companies and the doctors paid by them to 1) find asymptomatic conditions 2) call it 'disease' based on older studies of patients who were much sicker 3) 'treat' them with expensive medications for the rest of their lives without actually doing research to see if it would benefit or harm the patient.

caycep 9y ago
actually, the public health risk of stroke in paroxysmal AF is pretty high. Even if the expensive drugs weren't available, we'd still use coumadin which is dirt cheap. The elimination of stroke risk is worth the risk of bleeding complications.
- ghufran_syed 9y ago
  actually, you're assuming that the kinds of patients who were diagnosed with paroxysmal AF in the studies showing increased stroke risk 10 or 20 years ago are going to be similar in risk profile to asymptomatic patients who might now be diagnosed with paroxysmal AF based on some as yet underdetermined time criteria using new technology. To quote the paper: "Alternative arbitrary or data-derived atrial high-rate episodes burden cut points have been explored over the subsequent 10 years, ranging from 5 minutes to 24 hours.11 Uncertainty remains about the minimum burden that increases thromboembolic risk." On the other hand, there is no uncertainty about the degree of risk from bleeding (small, but present, and occasionally lethal). So yes, patients with paroxysmal AF based on current technology and clinical standards benefit more from reduction in stroke risk than they lose in bleeding risk. That doesn't mean that all patients in the future, with any degree of paroxysmal AF diagnosed using more sensitive technologies will benefit similarly
  - caycep 9y ago
    I think what you are trying to say is that - you think there may be varying "degrees" of PAF and that certain types may be less risky? That is something that certainly can be debated, but at least most of the of thinking so far is that any presence of PAF, aside from isolated episodes after cardiothoracic surgery, carries the same, if similar risk. I think the way my stroke colleagues look at it, is sort of the other way around - more like PAF is PAF, and as far as they can tell, based on current data, there is relatively few stratification levels that the current medical data can tell us. Meanwhile, the current assumption of risk from PAF, is so high, vs. the risk of anticoagulation (adjusted for individual patient, i.e. maybe not the patients with coagulopathies or risk of falls) that they view NOT anticoagulation as a higher risk. Because if one is wrong about it, the result is paralysis, coma or worse. If there are cheaper ways of detecting AF, all the better. But overall, anticoagulation decisions aside, think about it - this is a potentially a cheap way to passively screen for the condition in the population. Orders of magnitude so, and possibly w/ more accuracy than a typical holter monitor or even the newer implantable devices (which in all probability use simpler rhythm analysis). Even if you are worried about the potential existence of differing levels of AF, the wealth of new data should go a long way towards further understanding AF and figuring out whether differing levels of risk exist.

caycep 9y ago

actually, the public health risk of stroke in paroxysmal AF is pretty high. Even if the expensive drugs weren't available, we'd still use coumadin which is dirt cheap. The elimination of stroke risk is worth the risk of bleeding complications.

ghufran_syed 9y ago
actually, you're assuming that the kinds of patients who were diagnosed with paroxysmal AF in the studies showing increased stroke risk 10 or 20 years ago are going to be similar in risk profile to asymptomatic patients who might now be diagnosed with paroxysmal AF based on some as yet underdetermined time criteria using new technology. To quote the paper: "Alternative arbitrary or data-derived atrial high-rate episodes burden cut points have been explored over the subsequent 10 years, ranging from 5 minutes to 24 hours.11 Uncertainty remains about the minimum burden that increases thromboembolic risk." On the other hand, there is no uncertainty about the degree of risk from bleeding (small, but present, and occasionally lethal). So yes, patients with paroxysmal AF based on current technology and clinical standards benefit more from reduction in stroke risk than they lose in bleeding risk. That doesn't mean that all patients in the future, with any degree of paroxysmal AF diagnosed using more sensitive technologies will benefit similarly
- caycep 9y ago
  I think what you are trying to say is that - you think there may be varying "degrees" of PAF and that certain types may be less risky? That is something that certainly can be debated, but at least most of the of thinking so far is that any presence of PAF, aside from isolated episodes after cardiothoracic surgery, carries the same, if similar risk. I think the way my stroke colleagues look at it, is sort of the other way around - more like PAF is PAF, and as far as they can tell, based on current data, there is relatively few stratification levels that the current medical data can tell us. Meanwhile, the current assumption of risk from PAF, is so high, vs. the risk of anticoagulation (adjusted for individual patient, i.e. maybe not the patients with coagulopathies or risk of falls) that they view NOT anticoagulation as a higher risk. Because if one is wrong about it, the result is paralysis, coma or worse. If there are cheaper ways of detecting AF, all the better. But overall, anticoagulation decisions aside, think about it - this is a potentially a cheap way to passively screen for the condition in the population. Orders of magnitude so, and possibly w/ more accuracy than a typical holter monitor or even the newer implantable devices (which in all probability use simpler rhythm analysis). Even if you are worried about the potential existence of differing levels of AF, the wealth of new data should go a long way towards further understanding AF and figuring out whether differing levels of risk exist.