Unrecognized cobalamin deficiency, nitrous oxide, and reversible subacute combined degeneration

Abstract

FAHA: We thank Drs. Hart and Eikelboom 1 for their insightful commentary in Neurology ® Clinical Practice regarding the American Academy of Neurology (AAN) evidence-based guideline update on atrial fibrillation (AF). 2 Both authors have extensively researched stroke prevention in patients with AF 3 and we respect their views. The Commentary states, "atrial fibrillation patients with prior ischemic stroke or TIA benefit the most from anticoagulation and should receive anticoagulation, if it can be given safely." We could not agree more. The AAN guideline development process yields a Level B recommendation when clinicians "should" provide a therapy; a Level A recommendation is limited to situations when clinicians "must" provide a therapy. As the Commentary authors have implied, there are circumstances when anticoagulation cannot be safely given, and the guideline panel determined that clinical judgment was paramount in the final decision. Thus, a Level B was applied, which remains a strong recommendation. Cognizant of the AAN's global reach, we included a recommendation to consider the administration of triflusal (a generic product available in developing countries) with lowintensity acenocoumarol in patients with AF at intermediate stroke risk and higher bleeding risk (Level B). 4 In many developing countries, new oral anticoagulants may not be available or affordable, and this evidence-based recommendation fills the gap.