CORRESPONDENCE
that 80% or more of strokes with NRAF are preventable by anticoagulant therapy [2-4,7]. There are relatively few strokes in patients with NRAF that are not caused by cardiogenic emboli, or, more generally, that are not preventable by warfarin. Consequently, a strong risk factor for stroke in patients with AF would have to be a risk factor for strokes that are preventable by warfarin. Indeed, the Boston Area Anticoagulation Trial for Atria1 Fibrillation Investigators [2] specifically showed that increased age raised the risk of warfarin-preventable strokes among patients with NRAF, a finding fully supported by data from Framingham [6]. Exactly why aging leads to more embolic stroke is unclear. The pathophysiologic basis of the association of hypertension with NRAF-related stroke is complicated by the association of hypertension with nonembolic mechanisms (e.g., lacunar stroke). Nonetheless, we believe that hypertension’s as well as age’s effects should be explicitly studied and reported and not submerged by matching as suggested by Philbrick et al. We now know that warfarin prevents most strokes in AF. Unfortunately, our understanding of clinical features that increase stroke risk in NRAF is more primitive, and prevents optimal use of anticoagulant therapy. Our study indicated an approach to efficiently identify risk factors for stroke in NRAF. We believe our data support our carefully worded conclusion “that age and hypertension should be considered when deciding upon longterm anticoagulant therapy to prevent stroke in patients with nonrheumatic atrial fibrillation.” ANNE W.MOULTON,M.D. DANIEL E. SINGER,M.D. Rhode Island Hospital Providence, Rhode Island 1. Moulton AW. Singer DE, Haas JS. Risk factors for stroke in patients with nonrheumatic atrial fibrilla-
710
June
1992
The American
Journal
conclusions in this study and transmit them to patients. Given the general reluctance that patients have in accepting a psychiatric illness, physicians might consider sharing this study with 3. Stroke Prevention in Atrial Fibrillation Investigasuch patients to convince them of tors. Stroke Prevention in Atrial Fibrillation Study: the possibility of a psychiatric difinal results. Circulation 1991; 84: 527-39. 4. Petersen P. Godtfredsen J, Boysen G, Andersen agnosis. ED, Andersen B. Placebo-controlled, randomised Once more physicians gain trial of warfarin and aspirin for prevention of thromheart in suggesting a psychiatric boembolic complications in chronic atrial fibrilladiagnosis, it will follow that pation: the Copenhagen AFASAK study. Lancet 1989; 1: 175-9. tients will become more accept5. Bogousslavsky J, Van Melle G, Regli F, Kappening. Presently, for each physician berger L. Pathogenesis of anterior circulation who suggests a psychiatric illness, stroke in patients with nonvalvular atrial fibrillation: the Lausanne Stroke Registry. Neurology 1990; 40: there are several who will give al1046-50. ternative diagnoses such as “the 6. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation: chronic fatigue syndrome,” a major contributor to stroke in the elderly. Arch “Lyme disease,” or “chronic EpIntern Med 1987; 147: 1561-4. 7. Connolly SJ, Laupacis A, Gent M, Roberts RS, stein-Barr virus infection.” The Cairns JA, Joyner C. Canadian atrial fibrillation antiabundance of such physicians coagulation (CAFA) study. J Am Coil Cardiol 1991; lessens the credibility of those at18: 349-55. tempting to be truthful and accurate. Finally, once patients have CHRONICFATIGUE more acceptance of a psychiatric SYNDROMEAND PSYCHIATRIC diagnosis, the media will follow DISORDERS with reports of results similar to To the Editor: those found in this study and We read with great interest the public acceptance will grow even article by Lane et al [l] regarding more. the chronic fatigue syndrome. In DANIEL S. BERMAN,M.D. Westchester Square Medical our infectious disease practice, Cfmtm- - _- -. we frequently see patients comBronx, New York plaining of chronic fatigue. This BARRYD. WENGLIN.M.D. White Plains Hospital study confirms the clinical imWhite Plains, New York pression that we have about most 1. Lane TJ. Manu P, Matthews DA. Depression and of these patients. Our impression somatization in the chronic fatigue syndrome. Am J had not been based upon strict Med 1991; 91: 335-44. psychiatric criteria as the authors Submitted November 19, 1991, and accepted have used. January 29, 1992 Such an important study, which finally offers hope to those suffering with chronic fatigue, BONE DENSITY AND should have received enormous L-THYROXINETHERAPY media coverage. The impression To the Editor: that the public and many physicians now have about this syn- We read with interest the article drome is that there is no therapy by Greenspan et al [l] on bone available. Our guess is that the density in women given L-thymedia is unwilling to risk angerroxine. Although these authors ing those who would reject any point out that long-term treatment with L-thyroxine is associnotion that they could possibly have a psychiatric illness. ated with minimal changes in We hope, however, that physibone density, several points in cians take note of the important their study need to be addressed. tion: a case-control study. Am J Med 1991; 91: 156-61. 2. The Boston Area Anticoagulation Trial for Atrial Fibrillation Investigators. The effect of low dose warfarin on the risk of stroke in patients with nonrheumatic atrial fibrillation. N Engl J Med 1990; 323: 1505-l 1.
of Medicine
Volume
92
that 80% or more of strokes with NRAF are preventable by anticoagulant therapy [2-4,7]. There are relatively few strokes in patients with NRAF that are not caused by cardiogenic emboli, or, more generally, that are not preventable by warfarin. Consequently, a strong risk factor for stroke in patients with AF would have to be a risk factor for strokes that are preventable by warfarin. Indeed, the Boston Area Anticoagulation Trial for Atria1 Fibrillation Investigators [2] specifically showed that increased age raised the risk of warfarin-preventable strokes among patients with NRAF, a finding fully supported by data from Framingham [6]. Exactly why aging leads to more embolic stroke is unclear. The pathophysiologic basis of the association of hypertension with NRAF-related stroke is complicated by the association of hypertension with nonembolic mechanisms (e.g., lacunar stroke). Nonetheless, we believe that hypertension’s as well as age’s effects should be explicitly studied and reported and not submerged by matching as suggested by Philbrick et al. We now know that warfarin prevents most strokes in AF. Unfortunately, our understanding of clinical features that increase stroke risk in NRAF is more primitive, and prevents optimal use of anticoagulant therapy. Our study indicated an approach to efficiently identify risk factors for stroke in NRAF. We believe our data support our carefully worded conclusion “that age and hypertension should be considered when deciding upon longterm anticoagulant therapy to prevent stroke in patients with nonrheumatic atrial fibrillation.” ANNE W.MOULTON,M.D. DANIEL E. SINGER,M.D. Rhode Island Hospital Providence, Rhode Island 1. Moulton AW. Singer DE, Haas JS. Risk factors for stroke in patients with nonrheumatic atrial fibrilla-
710
June
1992
The American
Journal
conclusions in this study and transmit them to patients. Given the general reluctance that patients have in accepting a psychiatric illness, physicians might consider sharing this study with 3. Stroke Prevention in Atrial Fibrillation Investigasuch patients to convince them of tors. Stroke Prevention in Atrial Fibrillation Study: the possibility of a psychiatric difinal results. Circulation 1991; 84: 527-39. 4. Petersen P. Godtfredsen J, Boysen G, Andersen agnosis. ED, Andersen B. Placebo-controlled, randomised Once more physicians gain trial of warfarin and aspirin for prevention of thromheart in suggesting a psychiatric boembolic complications in chronic atrial fibrilladiagnosis, it will follow that pation: the Copenhagen AFASAK study. Lancet 1989; 1: 175-9. tients will become more accept5. Bogousslavsky J, Van Melle G, Regli F, Kappening. Presently, for each physician berger L. Pathogenesis of anterior circulation who suggests a psychiatric illness, stroke in patients with nonvalvular atrial fibrillation: the Lausanne Stroke Registry. Neurology 1990; 40: there are several who will give al1046-50. ternative diagnoses such as “the 6. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation: chronic fatigue syndrome,” a major contributor to stroke in the elderly. Arch “Lyme disease,” or “chronic EpIntern Med 1987; 147: 1561-4. 7. Connolly SJ, Laupacis A, Gent M, Roberts RS, stein-Barr virus infection.” The Cairns JA, Joyner C. Canadian atrial fibrillation antiabundance of such physicians coagulation (CAFA) study. J Am Coil Cardiol 1991; lessens the credibility of those at18: 349-55. tempting to be truthful and accurate. Finally, once patients have CHRONICFATIGUE more acceptance of a psychiatric SYNDROMEAND PSYCHIATRIC diagnosis, the media will follow DISORDERS with reports of results similar to To the Editor: those found in this study and We read with great interest the public acceptance will grow even article by Lane et al [l] regarding more. the chronic fatigue syndrome. In DANIEL S. BERMAN,M.D. Westchester Square Medical our infectious disease practice, Cfmtm- - _- -. we frequently see patients comBronx, New York plaining of chronic fatigue. This BARRYD. WENGLIN.M.D. White Plains Hospital study confirms the clinical imWhite Plains, New York pression that we have about most 1. Lane TJ. Manu P, Matthews DA. Depression and of these patients. Our impression somatization in the chronic fatigue syndrome. Am J had not been based upon strict Med 1991; 91: 335-44. psychiatric criteria as the authors Submitted November 19, 1991, and accepted have used. January 29, 1992 Such an important study, which finally offers hope to those suffering with chronic fatigue, BONE DENSITY AND should have received enormous L-THYROXINETHERAPY media coverage. The impression To the Editor: that the public and many physicians now have about this syn- We read with interest the article drome is that there is no therapy by Greenspan et al [l] on bone available. Our guess is that the density in women given L-thymedia is unwilling to risk angerroxine. Although these authors ing those who would reject any point out that long-term treatment with L-thyroxine is associnotion that they could possibly have a psychiatric illness. ated with minimal changes in We hope, however, that physibone density, several points in cians take note of the important their study need to be addressed. tion: a case-control study. Am J Med 1991; 91: 156-61. 2. The Boston Area Anticoagulation Trial for Atrial Fibrillation Investigators. The effect of low dose warfarin on the risk of stroke in patients with nonrheumatic atrial fibrillation. N Engl J Med 1990; 323: 1505-l 1.
of Medicine
Volume
92
