Optimizing anticoagulation management in atrial fibrillation: beyond the guidelines. How and for whom?

Atrial fibrillation (AF) is the most common arrhythmia with an increasing incidence with aging. It is associated with a 5-fold increased ischemic stroke risk and increased morbidity and mortality. Anticoagulation can reduce the stroke risk by two-thirds and, thus, it represents the cornerstone of therapeutic management.1 However, anticoagulant therapy is a double-edged sword. In fact, if on the one hand, anticoagulants guarantee a good ischemic stroke risk reduction, on the other hand, we must face an increased risk of incurring major and minor bleeding. To quantify both risks, several scoring systems have been proposed with CHA2DS2-VASc score and HASBLED being the most used to assess the stroke and hemorrhage risk respectively.1 Nevertheless, given the dynamic nature of stroke and bleeding risk, we need other tools to have a more in-depth and personalized choice of whether to anticoagulate or not and when. In fact, current guidelines recommend a permanent anticoagulation based on concomitant comorbidities and risk factors, regardless of the low AF burden, because of spontaneous termination or rhythm control strategies.2 A recent survey showed that 83.4% of AF patients presented multimorbidity and 55.5% of them were treated with polypharmacotherapy,3 which has been recently associated with 29% increased all-cause death and 39% cardiovascular death.4 Polypharmacy, beyond being a frailty marker, also represents one of the causes of drug adherence and drug–drug, drug–disease, and adverse drug interactions.5–7 Furthermore, the improving of oral anticoagulation management is also crucial in specific population such as the elderly, those with malignancies, and in patients with a bioprosthetic valve, in which the risk of major and life-threatening complications is high, regardless of the type of anticoagulation.8–10 Thus, it would be crucial in the future to try to reduce the pill burden in each patient and, with the growing AF prevalence in the general population, we also need innovative strategies and personalized choice of treatment. Papakonstantinou et al11 provided a good algorithm for the implementation of AF anticoagulation strategies, according to different patients' thromboembolic risk profile. Nowadays, in fact, technological improvements make it possible to have long-term monitoring of AF onset and duration, because of implantable devices, and consumer-grade digital health technologies. In addition, cumulative evidence in patients with pacemakers and defibrillators has reported that AF cannot be considered a dichotomous variable, but that it is the AF duration that confers an increased thromboembolic risk.12,13 Moreover, the breakthrough of new direct acting oral anticoagulants provides a rapid-onset of anticoagulation within few hours from administration and could give us the chance to start the therapy for a period and then stop it till a new event occurs. All these together may open a new future frontier in which anticoagulation could be taken only in response to a prolonged AF occurrence and for a limited time only.14 According to recent advances and to the algorithm reported by Papakonstantinou et al, it seems we can follow a new path for treating our patients. Moreover, most of the population own a smartphone, or other digital technologies able to passively monitor heart rate and rhythm for long periods at low cost, with a sensitivity and specificities over 95%.11 In addition, some manufacturers can also record a single lead ECG with automated rhythm adjudication. What is missing now is not the idea, but a huge amount of data to confirm these great findings - undermining old concepts and bringing to light, through new evidence, a greater benefit for our patients.