Long-Term Oral Anticoagulant Therapy in Patients With Unstable Angina or Suspected Non–Q-Wave Myocardial Infarction

Abstract

We congratulate Brignole et al 1 on their study. In particular, we found ourselves in agreement with their emphasis on the requirement for a (randomized) controlled trial in this field, a void which they have sought to fill. We are somewhat puzzled by their choice of control, however, and fear that it points to a gulf between the electrophysiology community and the heart failure community.Whilst it appears that the electrophysiologist's reaction to the copresentation of atrial fibrillation and congestive heart failure is to reach for his ablation catheter, our reaction to the copresentation of atrial fibrillation and congestive heart failure is to book an anaesthetist and reach for the defibrillator. We were surprised that nowhere did Brignole et al even mention the word "cardioversion," and neither did Dr Scheinman in his editorial, 2 despite the fact that he drew attention to the remarkable results that can be achieved with restoration of sinus rhythm. 3 It may be that cardioversion had been attempted in a number of patients (some might not even accept the diagnosis of "chronic" atrial fibrillation until electrical cardioversion has been tried and has failed), but nowhere is this information supplied. The mean duration of arrhythmia was fairly long but was exceeded by its standard deviation, so both groups must have included patients who had had atrial fibrillation for a relatively short time. We are not even told whether all the patients were still in atrial fibrillation at the end of the trial.We are not aware of a randomized controlled trial comparing the results of electrical cardioversion and medical therapy in patients with atrial fibrillation and congestive heart failure. The safety and efficacy of electrical cardioversion are so well founded that we would consider it unethical to conduct such a trial. The safety and efficacy of ablation and pacemaker insertion are not so well founded, however, and it would appear to us that the ideal comparison would be between ablation and cardioversion, not between ablation and medication. To have randomized half their patients to medication alone under these circumstances seems to us questionable. Andrew Davie, MB John McMurray, MD MRC Clinical Research Initiative in Heart FailureUniversity of Glasgow Glasgow, UK ResponseWe believe the electrophysiologist's reaction to the copresentation of atrial fibrillation and congestive heart failure is the same as that of the specialist in heart failure: namely, to make every effort to restore and maintain sinus rhythm for as long as possible. However, at least 12% of paroxysmal atrial fibrillation is considered intractable despite multiple-drug therapy and repeated cardioversions. 1 Moreover, in epidemiological studies, about 60% of patients with atrial fibrillation have a chronic form. In most cases, the main problem is not converting to sinus rhythm but maintaining it for a long time and avoiding the adverse effects of therapies necessary to obtain that goal. Thus, current treatments often fail to maintain stable sinus rhy...