On 2016 Jun 29, David D Leedahl commented:

In the accompanying editorial1, Calkins offers some insightful comments regarding the relatively high rate of stroke or TIA observed in the recent investigation by Gillinov et al.2 We would like to offer two important considerations related to these findings.

First, cardiac surgeons and physicians caring for cardiac surgical patients in the immediate postoperative period have a reluctance to initiate anticoagulant strategies for fear of bleeding complications. Accordingly, bridging strategies with parenteral anticoagulants are infrequently used when initiating warfarin therapy for POAF, potentially resulting in a greater length of time until therapeutic anticoagulation is achieved. Delaying anticoagulant initiation for one to two days to avoid bleeding and another two to three days to become therapeutic may leave patients unprotected for a longer period of time than recognized.

Secondly, using direct-acting oral anticoagulants for the treatment of POAF may improve the time to therapeutic anticoagulation and lower the bar for surgeons to decide to anticoagulate their patients. Although our hospital has some published experience with this approach,3 the effect on stroke or TIA incidence in patients with POAF remains uncertain.

Cornelius Dyke, M.D. Sanford Health, Fargo, ND 58122

David Leedahl, Pharm.D. Sanford Health, Fargo, ND 58122

1. Calkins H. Is Less More for the Treatment of Atrial Fibrillation after Cardiac Surgery? N Engl J Med 2016;374:1977-8.
2. Gillinov AM, Bagiella E, Moskowitz AJ, et al. Rate Control versus Rhythm Control for Atrial Fibrillation after Cardiac Surgery. N Engl J Med 2016;374:1911-21.
3. Anderson E, Johnke K, Leedahl D, Glogoza M, Newman R, Dyke C. Novel oral anticoagulants vs warfarin for the management of postoperative atrial fibrillation: clinical outcomes and cost analysis. Am J Surg 2015;210:1095-102; discussion 102-3.

On 2016 Jun 29, David D Leedahl commented:

In the accompanying editorial1, Calkins offers some insightful comments regarding the relatively high rate of stroke or TIA observed in the recent investigation by Gillinov et al.2 We would like to offer two important considerations related to these findings.

First, cardiac surgeons and physicians caring for cardiac surgical patients in the immediate postoperative period have a reluctance to initiate anticoagulant strategies for fear of bleeding complications. Accordingly, bridging strategies with parenteral anticoagulants are infrequently used when initiating warfarin therapy for POAF, potentially resulting in a greater length of time until therapeutic anticoagulation is achieved. Delaying anticoagulant initiation for one to two days to avoid bleeding and another two to three days to become therapeutic may leave patients unprotected for a longer period of time than recognized.

Secondly, using direct-acting oral anticoagulants for the treatment of POAF may improve the time to therapeutic anticoagulation and lower the bar for surgeons to decide to anticoagulate their patients. Although our hospital has some published experience with this approach,3 the effect on stroke or TIA incidence in patients with POAF remains uncertain.

Cornelius Dyke, M.D. Sanford Health, Fargo, ND 58122

David Leedahl, Pharm.D. Sanford Health, Fargo, ND 58122

1. Calkins H. Is Less More for the Treatment of Atrial Fibrillation after Cardiac Surgery? N Engl J Med 2016;374:1977-8.
2. Gillinov AM, Bagiella E, Moskowitz AJ, et al. Rate Control versus Rhythm Control for Atrial Fibrillation after Cardiac Surgery. N Engl J Med 2016;374:1911-21.
3. Anderson E, Johnke K, Leedahl D, Glogoza M, Newman R, Dyke C. Novel oral anticoagulants vs warfarin for the management of postoperative atrial fibrillation: clinical outcomes and cost analysis. Am J Surg 2015;210:1095-102; discussion 102-3.