We have read the report by Ramos et al. (1) in the Journal with great interest and excitement. The researchers have investigated patients from age 35 to 85 years with an ankle-brachial index (ABI) of 0.95 and without clinically recognized cardiovascular disease (CVD). They have categorized the patients as statin nonusers or new-users (first prescription or prescribed after at least 6 months) according to the beginning of statin treatment. The authors also stated that statin therapy was associated with a reduction in major adverse cardiac events and all-cause mortality among participants without clinical CVD, but with asymptomatic peripheral arterial disease (PAD), regardless of its low CVD risk. There are some issues that should be regarded in the interpretation of the study results.

There are several studies demonstrating a close relation between CHA2DS2-VASc scores and PAD. In the study by Violi et al. (2), PAD and atrial fibrillation was found to be a potentially dangerous combination. They found that comparison of vascular prevalence as assessed by CHA2DS2-VASc score and/or ABI ≤0.90 is of interest to define the potentially positive impact of measuring ABI in the management of patients with nonvalvular atrial fibrillation. In addition, the authors stated that “If ABI ≤0.90 was encompassed in the definition of vascular disease of CHA2DS2-VASc score, the prevalence of vascular disease increased in every risk class.” This issue should be clarified to correct the interpretation of the study results.

Lane et al. (3), in the clinician update “Use of the CHA2DS2-VASc and HAS-BLED Scores to Aid Decision Making for Thromboprophylaxis in Nonvalvular Atrial Fibrillation,” stated that use of risk schemas such as CHA2DS2-VASc and HAS-BLED can help to inform the choice of antithrombotic agent and the management strategy. Discussion of these risks with patients is essential, and this discussion over the patient's lifetime and treatment course plays a significant role in reducing any other possible events.

The CHADS2 score has been recently refined with the CHA2DS2-VASc score, which includes vascular disease as documented by a history of acute myocardial infarction, symptomatic PAD, or detection of atherosclerotic plaque in the aortic arch (4).

On the other hand, there are some doubts about the anticoagulation regime of the patients of this study. In this study, about 6% of patients had a diagnosis of atrial fibrillation. Presence of risk factors such as hypertension, diabetes, coronary artery disease, and old age in the study population is associated with thromboembolism, bleeding, and high mortality risk. Therefore, CHADS2 or CHA2DS2-VASc (5) scores should have been calculated and possible effects should have been explained before discussing the study results.

References

1

R. Ramos, M. Garcia-Gil, M. Comas-Cufi, et al.

Statins for prevention of cardiovascular events in a low-risk population with low ankle brachial index

J Am Coll Cardiol, 67 (2016), pp. 630-640

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2

F. Violi, G. Daví, W. Hiatt, et al.

Prevalence of peripheral artery disease by abnormal ankle-brachial index in atrial fibrillation: implications for risk and therapy

J Am Coll Cardiol, 62 (2013), pp. 2255-2256

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3

D.A. Lane, G.Y. Lip

Use of the CHA(2)DS(2)-VASc and HAS-BLED scores to aid decision making for thromboprophylaxis in nonvalvular atrial fibrillation

Circulation, 126 (2012), pp. 860-865

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4

G.Y. Lip, R. Nieuwlaat, R. Pisters, D.A. Lane, H.J. Crijns

Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro Heart Survey on Atrial Fibrillation

Chest, 137 (2010), pp. 263-272

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5

S. Rietbrock, E. Heeley, J. Plumb, T. van Staa

Chronic atrial fibrillation: incidence, prevalence, and prediction of stroke using the Congestive heart failure, Hypertension, Age >75, Diabetes mellitus, and prior Stroke or transient ischemic attack (CHADS2) risk stratification scheme

Am Heart J, 156 (2008), pp. 57-64

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