Capsule Commentary on Rivera-Caravaca et al., Soluble Fibrin Monomer Complex and Prediction of Cardiovascular Events in Atrial Fibrillation: The Observational Murcia Atrial Fibrillation Project

Capsule Commentary on Rivera-Caravaca et al., Soluble Fibrin Monomer Complex and Prediction of... Capsule Commentary on Rivera-Caravaca et al., Soluble Fibrin Monomer Complex and Prediction of Cardiovascular Events in Atrial Fibrillation: The Observational Murcia Atrial Fibrillation Project Bethany T. Samuelson Bannow, MD University of Washington, Seattle, WA, USA. J Gen Intern Med 33(6):945 ischemic stroke—the one outcome for which this marker DOI: 10.1007/s11606-018-4320-2 lacked any predictive value—and in many practices, the use © Society of General Internal Medicine 2018 of VKAs is being phased out in favor of newer, safer direct oral anticoagulants. As the authors state, this assay does not add significantly to the clinical utility of existing risk prediction models, and certainly at this point, it would be premature to base any ivera-Caravaca et al. report clinical outcomes in associ- clinical decisions upon these findings. However, the promis- ation with varying levels of soluble fibrin monomer ing findings of associations between high SFMC levels and complex (SFMC) in 1226 patients with atrial fibrillation re- important cardiovascular and mortality outcomes suggest that ceiving vitamin K antagonists (VKAs) for stroke prevention. further studies, ideally in patients who have not yet started The outcomes examined were highly clinically relevant and anticoagulation, may demonstrate clinical utility. The astute included ischemic stroke, a composite of adverse cardiovas- clinician will eagerly anticipate the results of such studies as cular events including mortality, cardiovascular mortality and they may yet be practice-changing. all-cause mortality. While associations between high SFMC levels (>12 μg/mL) and cardiovascular event and mortality outcomes were noted on multivariate analysis, no association Corresponding Author: Bethany T. Samuelson Bannow, MD; with ischemic stroke was found. University of Washington, Seattle, WA, USA (e-mail: Bts99@uw.edu). The CHA DS -VASc score, which utilizes seven clinical 2 2 features to predict risk of ischemic stroke among patients with Compliance with Ethical Standards: atrial fibrillation, is a well-established risk prediction model Conflict of Interest: The author has no conflicts of interest with this used to inform decision making regarding prophylactic article. anticoagulation in such patients. Acknowledging this, the authors appropriately investigated whether a finding of elevat- ed SFMC levels impacted the clinical usefulness of this pre- REFERENCES diction tool. No significant improvement was found. 1. Rivera-Caravaca JM, Roldán V, Romera M, Esteve-Pastor MA, Valdés This article is an excellent example of a well-planned and M, Lip GYH, Vicente V, Marín F. Soluble fibrin monomer complex and executed but early investigation of a biomarker. As such, prediction of cardiovascular events in atrial fibrillation: the observational Murcia atrial fibrillation project. J Gen Intern Med. https://doi.org/10. caution is required in interpreting the clinical relevance of 1007/s11606-017-4279-4 these findings. The most important limitation of this study is 2. Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrilla- that all patients were already on anticoagulation with VKAs. tion using a novel risk factor-based approach: the euro heart survey on As previously stated, the purpose of risk prediction models in atrial fibrillation. Chest. 2010;137:263–72. https://doi.org/10.1378/ the clinical care of patients with atrial fibrillation is generally chest.09-1584. to inform decisions regarding the initiation of anticoagulation. Furthermore, such decisions are generally based upon risk of Published online January 29, 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of General Internal Medicine Springer Journals

Capsule Commentary on Rivera-Caravaca et al., Soluble Fibrin Monomer Complex and Prediction of Cardiovascular Events in Atrial Fibrillation: The Observational Murcia Atrial Fibrillation Project

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Publisher
Springer US
Copyright
Copyright © 2018 by Society of General Internal Medicine
Subject
Medicine & Public Health; Internal Medicine
ISSN
0884-8734
eISSN
1525-1497
D.O.I.
10.1007/s11606-018-4320-2
Publisher site
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Abstract

Capsule Commentary on Rivera-Caravaca et al., Soluble Fibrin Monomer Complex and Prediction of Cardiovascular Events in Atrial Fibrillation: The Observational Murcia Atrial Fibrillation Project Bethany T. Samuelson Bannow, MD University of Washington, Seattle, WA, USA. J Gen Intern Med 33(6):945 ischemic stroke—the one outcome for which this marker DOI: 10.1007/s11606-018-4320-2 lacked any predictive value—and in many practices, the use © Society of General Internal Medicine 2018 of VKAs is being phased out in favor of newer, safer direct oral anticoagulants. As the authors state, this assay does not add significantly to the clinical utility of existing risk prediction models, and certainly at this point, it would be premature to base any ivera-Caravaca et al. report clinical outcomes in associ- clinical decisions upon these findings. However, the promis- ation with varying levels of soluble fibrin monomer ing findings of associations between high SFMC levels and complex (SFMC) in 1226 patients with atrial fibrillation re- important cardiovascular and mortality outcomes suggest that ceiving vitamin K antagonists (VKAs) for stroke prevention. further studies, ideally in patients who have not yet started The outcomes examined were highly clinically relevant and anticoagulation, may demonstrate clinical utility. The astute included ischemic stroke, a composite of adverse cardiovas- clinician will eagerly anticipate the results of such studies as cular events including mortality, cardiovascular mortality and they may yet be practice-changing. all-cause mortality. While associations between high SFMC levels (>12 μg/mL) and cardiovascular event and mortality outcomes were noted on multivariate analysis, no association Corresponding Author: Bethany T. Samuelson Bannow, MD; with ischemic stroke was found. University of Washington, Seattle, WA, USA (e-mail: Bts99@uw.edu). The CHA DS -VASc score, which utilizes seven clinical 2 2 features to predict risk of ischemic stroke among patients with Compliance with Ethical Standards: atrial fibrillation, is a well-established risk prediction model Conflict of Interest: The author has no conflicts of interest with this used to inform decision making regarding prophylactic article. anticoagulation in such patients. Acknowledging this, the authors appropriately investigated whether a finding of elevat- ed SFMC levels impacted the clinical usefulness of this pre- REFERENCES diction tool. No significant improvement was found. 1. Rivera-Caravaca JM, Roldán V, Romera M, Esteve-Pastor MA, Valdés This article is an excellent example of a well-planned and M, Lip GYH, Vicente V, Marín F. Soluble fibrin monomer complex and executed but early investigation of a biomarker. As such, prediction of cardiovascular events in atrial fibrillation: the observational Murcia atrial fibrillation project. J Gen Intern Med. https://doi.org/10. caution is required in interpreting the clinical relevance of 1007/s11606-017-4279-4 these findings. The most important limitation of this study is 2. Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrilla- that all patients were already on anticoagulation with VKAs. tion using a novel risk factor-based approach: the euro heart survey on As previously stated, the purpose of risk prediction models in atrial fibrillation. Chest. 2010;137:263–72. https://doi.org/10.1378/ the clinical care of patients with atrial fibrillation is generally chest.09-1584. to inform decisions regarding the initiation of anticoagulation. Furthermore, such decisions are generally based upon risk of Published online January 29, 2018

Journal

Journal of General Internal MedicineSpringer Journals

Published: Jan 29, 2018

References

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