The original contribution of Gage et al 1 on the underuse of antithrombotic therapy in Missouri Medicare draws attention to the resistance for general physicians to prescribe this therapy.Data from our stroke register further emphasize this problem. In the Emergency Department of Fatebenefratelli Hospital (a central hospital in Milan, Italy), we are following an observational study on acute cerebrovascular accidents. Over approximately 20 months, we have recorded 1009 consecutive patients (884 with ischemic stroke, 88%; 125 hemorrhagic, 12%). In patients with ischemic stroke or transient ischemic attack (TIA) and presence of chronic nonvalvular atrial fibrillation (NVAF), we recorded the domiciliary therapy and the presence of additional stroke risk factors: age Ͼ75 years, previous ischemic stroke or TIA, previous diagnosis of arterial hypertension, chronic congestive heart failure, chronic ischemic heart disease, or type I or II diabetes. One hundred twenty-two of 884 ischemic patients (13.8%) had NVAF. Only 49 patients (40.2%) were taking antithrombotic therapy: aspirin (nϭ31, 25.4%), ticlopidine (nϭ6, 4.9%), indobufen (nϭ4, 3.3%), and oral anticoagulant (nϭ8; 6.6%); 73 patients (59.8%) were taking no prophylactic antithrombotic therapy. Associated risk factors were present in 96% of the patients: 21 patients (7 with prophylactic therapy and 14 not treated, 17.2%) had 1 risk factor, 39 patients (13 treated and 26 not treated, 31.9%) had 2 risk factors, and 57 patients (28 treated and 29 not treated) had Ն3 risk factors. The individual risk factors are presented in the Table. The importance of atrial fibrillation as a risk factor for stroke is well known. It has been demonstrated that the majority of strokes in patients with atrial fibrillation can be prevented by prophylactic antithrombotic therapy. Moreover, the presence of additional cardiovascular risk factors is an indication for antithrombotic therapy. [2][3][4] In our study we have shown that patients with NVAF and other stroke risk factors still do not receive a good treatment. Prophylactic antithrombotic therapy is underutilized in NVAF patients, and despite the recent published guidelines and recommendations, 5 many physicians remain hesitant to prescribe antithrombotic therapy. The actual debate may be whether aspirin or anticoagulation is the treatment of choice; 6 our data show, however, that it is still necessary, as a preliminary action, to emphasize to generalists that in a patient with NVAF any antithrombotic therapy is better than nothing.
