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We read with interest the article by Evans and Kalra¹ recently published in the ARCHIVES, and we have some concerns about their conclusions. By stating that patients undergoing anticoagulation (AC) therapy in clinical practice have stroke and major bleeding rates similar to those of patients in randomized controlled trials, the authors suggest that warfarin underuse depends exclusively on physician malpractice. We disagree; interpretation of the results should be more prudent.

In their analysis of the English study,² the authors find that the annual rate of the combined intracranial hemorrhages and major bleeding events strictly approximates the annual risk of stroke (1.6 vs 2.0, respectively). This does not address the risk-benefit component of AC therapy; hemorrhage incidence proportionally increases with age.³ A second flaw in the review is the decision of the authors to analyze data from 3 studies and a nursing home.⁴ Nursing home residents are in a poorer state . . . [Full Text of this Article]

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