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Standards in dementia care

the NICE guidance has rather a ‘blunt’ risk stratification system where co-morbidities such as diabetes and vascular disease do not make an independent contribution, unlike in CHADS2. Given the limitations of this scoring, it may be better practice in octogenarians when making decisions on primary stroke prevention to use CHADS2 preferentially for this group of older patients. The study group did appear rather atypical given the low percentage of diabetic patients (3% in the warfarin group and 5% in the aspirin group), compared with other studies that have found this co-morbidity in 16.5% of elderly patients [4]. Although diabetes is part of the CHADS2 risk stratification in AF, diabetic patients often have small vessel disease and consequently a higher risk of bleeding with warfarin thus influencing the choice between aspirin and warfarin for stroke prevention [5]. This is an interesting study but, as hinted at by the authors in their conclusion, has limited application in clinical practice. It does, however, highlight that with careful stratification of individual risks in AF and subsequent anticoagulation there is a group of patients traditionally viewed as ‘high-risk’ for such intervention who could safely decide to choose warfarin rather than aspirin.