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This editorial refers to ‘The likelihood of decreasing strokes in atrial fibrillation patients by strict application of guidelines' by R. Pisters et al ., on page 779. Randomized trials in patients with atrial fibrillation (AF) have consistently demonstrated that compared with placebo, adjusted-dose vitamin K antagonists (VKAs) reduce the incidence of stroke by ∼65%, whereas antiplatelet agents reduce stroke by ∼20%.1 Despite existing evidence and guidelines, several observational studies have demonstrated suboptimal use of oral anticoagulation in clinical practice. For example, the EuroHeart Survey in AF reported that although the application rate of VKAs had generally improved, antithrombotic drug therapy was only modestly tailored to guidelines.2 Appreciation that adherence to guidelines is suboptimal is one thing; understanding the reasons for this situation and its consequences and finally attempting at better adherence to guidelines are a different issue.In this issue of the Journal, Pisters et al .3 report that many patients with known AF admitted for ischaemic stroke to a university medical centre did not receive adequate antithrombotic treatment on admission and 51% patients with known AF who were eligible for VKA did not actually receive it. Indeed, an improved antithrombotic guideline adherence could have potentially prevented 22% of the ischaemic strokes. Moreover, at least 10% of patients at discharge were still insufficiently protected against recurrent stroke.These observations are even more alarming than those from the EuroHeart Survey on AF in whom participating centres chose to include or not their patients on an individual basis,2 thus resulting in a possible bias. Nevertheless, these findings represent a systematic analysis of a ‘real world’ cohort of patients. Additional analyses of the factors leading to undertreatment would have been of interest, because the parameters associated with undertreatment may be broadly classified in two categories: those related to the patient …

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Guidelines for antithrombotic therapy in atrial fibrillation: understanding the reasons for non-adherence and moving forwards with simplifying risk stratification for stroke and bleeding