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LETTER TO EDITOR  
Ahead of print publication
Anticoagulation for atrial fibrillation in children; one size doesn't fit all!


 Department of cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Click here for correspondence address and email

Date of Submission27-May-2020
Date of Acceptance22-Jul-2020
Date of Web Publication17-Sep-2020
 


How to cite this URL:
Naganur SH, Vijay J, Barwad P. Anticoagulation for atrial fibrillation in children; one size doesn't fit all!. Ann Pediatr Card [Epub ahead of print] [cited 2020 Oct 24]. Available from: https://www.annalspc.com/preprintarticle.asp?id=295227




Sir,

With great interest, we read the recently published consensus article on “Indian guidelines for management of congenital heart disease” in your prestigious journal.[1] Although we commend the authors for their comprehensive approach, the following issues are worth considering regarding therapeutic anticoagulation for atrial fibrillation (AF) in children with valvular heart disease.

The authors suggest using anticoagulation in all cases of mitral and aortic regurgitation in the presence of AF (vide section “the role of drug therapy in mitral and aortic regurgitation”). This also finds a place in an abridged secondary publication in Indian Paediatrics, page no 155, Volume 57_February 15, 2020. This statement is not based on any evidence-based study and looks like a consensus statement by the authors.

There is little doubt if anticoagulation therapy is effective in reducing stroke risk in AF. However, there is insufficient evidence for a blanket/universal anticoagulation strategy for patients with AF in nonvalvular etiology or any valvular heart diseases except mitral stenosis and metallic prosthetic valves. Conventionally, many trials of anticoagulation for AF for stroke risk estimation have excluded this population.[2]

Recent guidelines recommend the use of CHA2 DS2-Vasc score in mitral and aortic regurgitation for a tailored decision making except in those with moderate-to-severe mitral stenosis and prosthetic valves.[3] As there are no enough data on the use of CHA2 DS2-Vasc score for anticoagulation in AF in children, we will have to extrapolate the adult patient data to pediatric population. In a patient with AF and a CHA2 DS2-Vasc score of 0, the risk to benefit ratio rarely favors anticoagulation. Anticoagulation therapy needs to be considered in patients with CHA2 DS2-Vasc score of 2. Thus, the risks and benefits of anticoagulation therapy and the important issues of compliance in children need to be discussed in detail with parents and caretakers for a shared decision-making. This is because children are more likely to get injured consequent to their more active lifestyle and participation in sports. The risk of fatal internal bleeding is much more when it comes to contact sports and anticoagulation.[4] Moreover, restriction of physical activity is not routinely recommended in children to encourage and ensure proper physical growth and psychomotor development. We would also like to bring into notice that the percentage of the pediatric population who are in target therapeutic anticoagulation range despite proper monitoring is very less, and until now, there is no documented evidence to use novel anticoagulation in this subset of population.

Let our children be more physically active. Risk stratification for “decision to anticoagulate” in AF will avoid unnecessary health-care expenditure and the untoward hassles of anticoagulation, especially when there is no enough evidence on the absolute benefit of anticoagulation in this subgroup.[5] We need head-to-head prospective randomized controlled trials to address this issue.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Saxena A, Relan J, Agarwal R, Awasthy N, Azad S, Chakrabarty M, et al. Indian guidelines for indications and timing of intervention for common congenital heart diseases: Revised and updated consensus statement of the Working group on management of congenital heart diseases. Ann Pediatr Cardiol 2019;12:254-86.  Back to cited text no. 1
    
2.
Olesen JB, Lip GY, Hansen ML, Hansen PR, Tolstrup JS, Lindhardsen J, et al. Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation: nationwide cohort study. BMJ. 2011;342:d124. Published 2011 Jan 31. doi:10.1136/bmj.d124  Back to cited text no. 2
    
3.
Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Fleisher LA, et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2017;70:252-89.  Back to cited text no. 3
    
4.
Berkowitz JN, Moll S. Athletes and blood clots: Individualized, intermittent anticoagulation management. J Thromb Haemost 2017;15:1051-4.  Back to cited text no. 4
    
5.
Lip GYH, Collet JP, Caterina R, Fauchier L, Lane DA, Larsen TB, et al. Antithrombotic therapy in atrial fibrillation associated with valvular heart disease: A joint consensus document from the European Heart Rhythm Association (EHRA) and European Society of Cardiology. Europace 2017;19:1757-8.  Back to cited text no. 5
    

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Correspondence Address:
Jyothi Vijay,
Department of cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/apc.APC_122_20





 

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