To the Editor The excellent article by Chatterjee et al1 underlines the effectiveness and safety of novel oral anticoagulants over warfarin in terms of major bleeding (intracranial hemorrhage). Several recent studies, such as ROCKET-AF (Rivaroxaban Once-daily oral direct factor Xa inhibition Compared with vitamin K antagonism for prevention of stroke and Embolism Trial in Atrial Fibrillation), RE-LY (Randomized Evaluation of Long Term Anticoagulant Therapy with Dabigatran Etexilate), AVERROES (Apixaban Versus Acetylsalicylic Acid to Prevent Strokes), and ARISTOTLE (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation), demonstrated the superiority (or noninferiority, depending on the dose) of newer anticoagulants vs vitamin K antagonists, in terms of risk reduction for stroke and major bleedings, using an easier and apparently safer drug regimen. However, all these studies, and the meta-analysis of Chatterjee et al, had a major limitation: blood pressure control during follow-up has not been assessed. The prevalence of arterial hypertension in the participants of these studies was extremely high; it ranged from 80% to 90%.2 It is well known that hypertension is associated with increased risk for stroke as well as with major bleeding. The presence of systolic blood pressures higher than 160 mm Hg is among the clinical characteristics of the HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol concomitantly) score, while in the CHA2DS2VASc (congestive heart failure, hypertension, 75 years of age and older, diabetes mellitus, previous stroke or transient ischemic attack, vascular disease, 65 to 74 years of age, female) score, hypertension represents a major risk factor. Thus, apart from the comparison of vitamin K antagonists with novel oral anticoagulants, blood pressure control also plays a significant role for the reduction of major bleeding. In terms of stroke incidence, in the combined SPORTIF (Stroke Prevention Using Oral Thrombin Inhibitor in Atrial Fibrillation) III and V cohort, the event rate for stroke/systemic embolic events increased markedly at mean systolic blood pressure rates of greater than 140 mm Hg.3,4
Kallistratos MS, Poulimenos LE, Manolis AJ. New Oral Anticoagulants and the Risk for Intracranial Hemorrhage. JAMA Neurol. 2014;71(3):370–371. doi:10.1001/jamaneurol.2013.5963
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