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I n their retrospective follow-up study of all patients attending a hospital anticoagulant clinic for atrial fibrillation, Copland and colleagues found that the elderly population has both good anticoagulant control and a low incidence of hemorrhage while receiving warfarin therapy. Although interesting, from our point of view, these data cannot support the authors’ general conclusion in favor of anticoagulant use. In fact, in the “Patients, Materials, and Methods” section, the authors note that prosthetic heart valve replacement was the only exclusion criterion, implicitly admitting the possibility of “a selection bias at the level of referral to the clinic.” We would like to comment on this bias with our recent data, reporting that global cognitive, functional, and comorbidity status strongly influence the assignment to aspirin or anticoagulant therapy in the elderly population both in the hospital and in the community. In particular, we also found that among general practitioners in the community, the assessment of the patients’ walking independence is critical in the decision to start anticoagulation treatment. In light of these considerations, it is very likely that the patients attending the anticoagulant clinic in the study of Copland and colleagues were the most healthy, thus representing only a small proportion of total potential beneficiaries. The question is not whether anticoagulation is effective to prevent stroke, but whether all elderly patients with atrial fibrillation may be considered eligible for warfarin treatment, even when poor health status might be an obstacle to compliance.

Let's Strip the King: Eligibility Not Safety Is the Problem of Anticoagulation for Stroke Prevention in Elderly Patients With Atrial Fibrillation