IJCS | Volume 33, Nº1, January / February 2019

66 patients with high CHA2DS2VASc and high HAS-BLED (prevalent study population), and increases the risk of bleeding in this population. In the study by Geraldes et al., 7 the variables previous AF episode (p < 0.001), hypertension (p < 0.001) and low HAS-BLED score were predictors of anticoagulation, while increased serum creatinine (p < 0.002), increased LA (p = 0.003) and presence of biological prosthesis (p = 0.007) were predictors inversely associated with the prescription of DACs, i.e., they were predictors of warfarin prescription. Each 1 mg/ml increase in serum creatinine led to 82% less chance of patients using DACs, reflecting the rejection of anticoagulating patients with impaired renal function despite the safety demonstrated in patients with clearance of up to 30 mg/ml with all DACs. They also demonstrated a high correlation between HAS-BLED and CHA2DS2VASc in the study population, which reflects the reality of AF patients with a high rate of associated comorbidities and a high risk of both thromboembolic events and major bleeding. Of the total population evaluated in the study, 75% were discharged on oral anticoagulation (20% VKA and 55% DACs) and the vast majority had a history of AF (p = 0.001) and TIA/stroke (p = 0.008), were elderly (p = 0.005) and had smaller HAS-BLEDs with higher weights. Surprisingly, 93 patients referred for anticoagulation were discharged without using such drugs and, in this group, 54% (50 patients) had no reason for not using them or the reasons were inconsistent with the medical literature. The authors also point out, which seems extremely relevant, that some physicians did not apply the CHA2DS2VASc risk score to assess patients’ thromboembolic risk. Instead, they used only their clinical impression, which is often inaccurate, although the population’s average CHA2DS2VASc was as high as 3.4 +-2. Of the 208 patients onDACs, 63 (30%) had inadequate prescriptions for severe interactions and 58 patients were prescribed inadequate doses for the patient profile. Doses beloweffective levels were themost common error found. Marzec et al., 8 in an article published in the JACC in 2017 (7), studied 655,000 patients with risk score CHA2DS2VASc > 1 in the PINNACLE registry, where they analyzed the use of warfarin and DACs in non-valvular AF. The authors also concluded that the introduction of DACs in clinical practice was associated with improved rates of anticoagulation for AF but many gaps were still to be filled and variations in clinical practice were quite inconsistent regarding anticoagulationwithDACs. These authors reported that DACs were preferably used in patients with few comorbidities, low risk of ischemic stroke and in those previously anticoagulated with warfarin. The authors suggested that further studies would be needed to better define the factors associated with variations and underuse of DACs in patients with high risk of ischemic stroke, emphasizing the importance of applying specific strategies to reduce the risk of ischemic stroke in patients with AF. Monelli et al., 9 in a single-center prospective observational real-life Italian study assessed records of patients using DACs (the REGINA study — registry of patients on non-vitamin K oral anticoagulants), which included 227 patients with mean age of 81.6 years (about 80% > 80 years of age) and mean CHA2DS2vasc of 5 and HAS-BLED of 4, with mean clearance of 59.2 and concluded that in a population of elderly and clinically complex patients, especially octogenarians, a population that is similar to the study discussed here, DACs were safe and effective and the careful follow-up of these elderly people with a high treatment adherence rate contributed to better prognosis in this population (8). Another study evaluating anticoagulation in AF, the ORBIT-AF study (outcomes registry for better quality of care in the treatment ofAF) showed a higher prevalence of DAC use amongAF patients seen by electrophysiologists compared with clinical cardiologists and primary care physicians or generalists. This is probably due to the fact that electrophysiologists receive the referral of a larger number of patients without contraindication for anticoagulation, because after an ablative procedure, full anticoagulation is recommended, i.e., they deal with a previously selected population. 10 In conclusion, the study by Geraldes et al., 7 realistically portrays the current situation of AF anticoagulation in our community, highlighting an important advance in the use of anticoagulation, especially DACs, but also drawing attention to improvements in this practice, which requires significant and urgent changes in order to use oral anticoagulation at discharge in this population with higher thromboembolic risk as a quality factor inAF care and an important indicator of primary prevention in public health. Bronchtein et al. Anticoagulation in atrial fibrillation Int J Cardiovasc Sci. 2020;33(1):65-67 Editorial