LAUSR

Dear Editor, We have read with great interest the article published in your journal titled “Predictors of stroke or systemic embolism in patients with nonvalvular atrial fibrillation with CHA2DS2VASc score of 0” by Choi et al. (2023). The authors evaluated the predictors of atrial fibrillation in patients with CHA2DS2VASc score of 0. We would like to draw attention to a few points about this article. The major finding of the study was that risk of stroke or embolism rate was very low. Interestingly, the most of the patients were followed up without anticoagulation and no stroke was observed. We believe that especially the short followup period has shown a significantly lower risk of stroke in the study. On the other hand, it has been reported that atrial fibrillation (AF) is observed in 24% of all strokes and 12% in nonfatal strokes (Akyea et al., 2021; Tsao et al., 2022). Considering the retrospective nature of the study and the fact that two patients were even on anticoagulants, it may be difficult to say exactly how many of the patients who reached the primary outcome were guilty of AF. Another point, the fact that patients with left ventricular end diastolic diameter of 46 mm and above were not evaluated in terms of heart failure with preserved ejection fraction (HFpEF) seems to be the limitation of the study. It is possible that the CHA2DS2VASc score was calculated as 0 even though some patients had heart failure, ignoring the fact that the incidence of heart failure is approximately 1% especially under the age of 55, the lack of natriuretic peptide evaluation and the threshold for the resting E/e’ ratio is 9 in HFpEF diagnosis (McDonagh et al., 2021). Finally, we would like to draw attention to obesity that is important in the development of AF and stroke and systemic embolism, as the mean weight was almost close to overweight range in the study. We also have seen that age is actually an important predictor in terms of shedding light on future studies on the prediction of outcomes.