Stroke and atrial fibrillation: To anticoagulate or not

After reviewing these published studies, I think one can conclude that in the patient population with chronic and/or paroxysmal atrial fibrillation, warfarin is beneficial and the benefits outweigh the risks. However, it is important to point out that patients at high risk for embolic disease, for example, dilated cardiomyopathy patients, were rarely included in these trials. The five trials mentioned above do not address this patient population. Current opinion is that these individuals should receive anticoagulation despite the lack of objective evidence that anticoagulation is beneficial if the risk of bleeding is not excessive. The five trials also do not address the population of patients categorized as having "lone atrial fibrillation," that is, atrial fibrillation occurring in patients with no structural heart disease. The general consensus in the low embolic risk patient, (i.e., the patient < 60 years of age who has lone atrial fibrillation) is that the risk of anticoagulation is greater than the benefit. My final thought on the subject concerns the risk of pulmonary emboli in this patient population. My guess is that this group of patients is at high risk for small pulmonary emboli, which in many instances may be subclinical--for example, clots too small to result in persistent tachypnea or tachycardia. As far as I can tell, there are no randomized trials on the prevention of pulmonary emboli in patients with chronic or paroxysmal atrial fibrillation using anticoagulation or aspirin. I guess the systemic emboli trial data are sufficient to indicate a protective effect on the lungs as well as on the brain.(ABSTRACT TRUNCATED AT 250 WORDS)