Two year f/u is too short. In real practice decades of life must be protected. A 60-70 y.o. must be protected to age 80-90 (or longer). Extrapolate that low percentage of mostly minor strokes to 10-15 times as long as 2 years and the total number of strokes is not so low and the not so minor events are not so rare.
Further, my intuition is that the cumulative stroke incidence over time will be non linear, will accelerate. My reasoning is that new clot will build and grow on older mural clot, gaining thickness while both losing mechanical strength and protruding deeper into the flow of atrial blood.
I remember atrial fib patients with embolic stroke and embolic MI. When warfarin anticoagulation was became recommended for patients with atrial fibrillation I'd already been in clinical medicine more that 20 years and in private practice for 17. The ordeal of warfarin: chasing protimes with dose adjustments, overshoot bruising and bleeding and the thromboembolic events due to inadequate dosing, were significant vs. the dosing simplicity and the efficacy we now enjoy with direct acting oral medications. Let me pass this on to the current generation of physicians and urge that we don't regress based on a short 24 month study.
You didnt mention external validity and extrapolating findings from a South Korean population to a Western one?
Two year f/u is too short. In real practice decades of life must be protected. A 60-70 y.o. must be protected to age 80-90 (or longer). Extrapolate that low percentage of mostly minor strokes to 10-15 times as long as 2 years and the total number of strokes is not so low and the not so minor events are not so rare.
Further, my intuition is that the cumulative stroke incidence over time will be non linear, will accelerate. My reasoning is that new clot will build and grow on older mural clot, gaining thickness while both losing mechanical strength and protruding deeper into the flow of atrial blood.
I remember atrial fib patients with embolic stroke and embolic MI. When warfarin anticoagulation was became recommended for patients with atrial fibrillation I'd already been in clinical medicine more that 20 years and in private practice for 17. The ordeal of warfarin: chasing protimes with dose adjustments, overshoot bruising and bleeding and the thromboembolic events due to inadequate dosing, were significant vs. the dosing simplicity and the efficacy we now enjoy with direct acting oral medications. Let me pass this on to the current generation of physicians and urge that we don't regress based on a short 24 month study.
I very much appreciate your perspective!