In reply: Atrial fibrillation management: Issues of concern

In Reply: Dr. Chao raises several important points regarding our manuscript on the management of newly diagnosed atrial fibrillation.¹

Dr. Chao mentions some of the complications of pulmonary vein antrum isolation. A review of catheter ablation for atrial fibrillation was outside the scope of our manuscript, so the details of the procedure and potential complications were not covered. Dr. Chao does mention some of the important potential complications. However, the complication rates he cites are not generally supported by the available medical literature. Thermal mucosal injury of the esophagus was reported at rates as low as 4% in the same studies cited by Dr. Chao in patients undergoing pulmonary vein antrum isolation with conscious sedation. The rate of 47% was seen in patients undergoing the procedure with general anesthesia. The rate of atrio-esophageal fistula is not well known. As of 2010, about 49 cases were reported in the literature.² Rates have been described ranging from 0.01% to 0.2%,^3–9 far lower than the rate mentioned by Dr. Chao. A careful review with the patient of the risks, benefits, and alternatives is standard practice before any elective, invasive procedure.

Multiple anticoagulation schemes have been proposed, including the Birmingham 2009 scheme.¹⁰ We included the CHADS₂ score in our paper because it is widely accepted and well validated. The Birmingham 2009 scheme acknowledges other potential risk factors such as female sex, history of vascular disease, and age between 65 and 75 years. It will be interesting to see if it will ever supplant the CHADS₂ score. However, no risk stratification scheme should replace sound clinical judgment. Individual patient factors must be considered when deciding whether anticoagulation is appropriate for an individual patient.