I found a nice paper @sachinjshah et al, re *net* benefits from oral AC in AF based on competing risks As competing risks increase OAC benefit decreases. As life expectancy decreases, benefit also decreases CHADSVASC is too simple Do read the paper in @CircOutcomes ahajournals.org/doi/abs/10.116… cc @GBarnesMD
@drjohnm @sachinjshah @CircOutcomes This finding is equally true for the harms of anticoagulation. Since anticoagulation doesn't have a legacy effect, where treatment now helps in the future, isn't the real Q the short-term risk vs. benefit?
@drjohnm @sachinjshah @CircOutcomes True. It’s definitely and individualized discussion. But most studies I’ve seen show vast majority of people would prefer a GIB risk over disabling stroke. Many including myself would even prefer death over disabling stroke.
@drjohnm @sachinjshah @CircOutcomes Nice paper which illustrates an important clinical concept. It is also underappreciated that the degree of competing risk actually increases along with the CHADSVASc score. ahajournals.org/doi/10.1161/CI…
@drjohnm @sachinjshah @CircOutcomes Nice paper and important concept at how isolated benefits are attenuated by competing risks. However, one should note that paper looks only at VKA and not all oral OAC such as DOACs...or alternative strategies like LAAO. 😉
@drjohnm @sachinjshah @CircOutcomes Thank you! We need more data to change paradigm, correct? What else should we rely on?
@drjohnm @sachinjshah @CircOutcomes can you help me understand how we can account for “death” in the prediction. It is rather feasible to do it in a retrospective cohort using time-to-event as an outcome. But how can we say “if you die before you get a stroke, your benefit of anticoagulation is lower”?
@drjohnm @sachinjshah @CircOutcomes This is rather a classic property of sub- hazard ratios vs. hazard ratios when we account for a mutually exclusive competing risk. “Lower” benefit of anticoagulation for the outcome, is accounted for by death as “death” event is not considered “ censored”
@drjohnm @sachinjshah @CircOutcomes @drjohnm thank you for highlighting the article and yet our practice has not changed. Number of my patients on HD r on AC. Is it because we r afraid to stop AC in AF in dialysis patients or there is not enough data to support stoppage of AC. I suspect bit of all. Many thanks
@drjohnm @sachinjshah @CircOutcomes AC is usually started appropriately and thoughtfully, however it’s frequently left on the med list and is forgotten or docs are too scared to D/C. I’m biased from my time as a trauma resident seeing many geriatric patients fall & have devastating head bleeds