10 CHAPTER 1 THE CASE OF MRS. DE JONG Mrs. de Jong is 80-years old and has been living alone since her husband died two years ago in 2018. She is frequently visited by her general practitioner (GP), most often for complaints of pain caused by coxarthrosis and shortness of breath due to heart failure; both reasons why she no longer manages to go out for grocery shopping on her own. In addition, she is known with hypertension, mitral valve insufficiency, vascular disease, diabetes mellitus, presbycusis, and mild cognitive impairment. Her medication list includes six different types of drugs. May 2020 – Her GP receives a phone call from her worried son. Mrs. de Jong has been admitted with coronavirus disease 2019 (COVID-19) and has also developed atrial fibrillation (AF) during admission. The GP had previously read an interesting paper in the journal ‘Huisarts & Wetenschap’, stating that during a respiratory tract infection patients are more prone to developing cardiovascular diseases, including AF, and that they are in an increased prothrombotic state. The GP wonders whether the pathophysiology of an increased ischaemic stroke risk in AF is actually fully understood and whether everything the GP learned about it at medical school is still valid. The son of Mrs. de Jong brings the GP back to reality; he fears that his mother will not survive the admission given these two diseases new to her and her advanced age. He asks whether her GP can tell him anything about her risk of dying. Unfortunately, the GP has to explain that it is not possible to predict mortality risk, because there is still very little known about the impact of COVID19. July 2020 – Mrs. de Jong survived the hospital admission and is back home where daily home care has been initiated by her GP. Her AF appeared to be permanent. This means, considering her CHA2DS2-VASc score of 5, that her ischaemic stroke risk would be 8.4% per year on average if left untreated.1 A vitamin K antagonist oral anticoagulant (VKA) was started during hospitalisation. According to the available evidence, a VKA will reduce her ischaemic stroke risk by 67% (from 8.4% to 2.8% per year; i.e. an absolute risk reduction of 5.6% per year) .2 Thus, although accompanied by an increase in major bleeding (from around 0.9% to 1.5% per year),2 there is no doubt that Mrs. de Jong should receive oral anticoagulation. Importantly, her GP wonders how certain the optimal threshold of the CHA2DS2-VASc score above which oral anticoagulation should be initiated (i.e. 3 for women and 2 for men) actually is. Moreover, the GP wonders why the cardiologist chose a VKA instead of a non-VKA oral anticoagulant (NOAC) given that cardiologists are increasingly prescribing NOACs instead of VKAs when initiating oral anticoagulation in AF patients. April 2023 – For several months, Mrs. de Jong complains that she suffers more frequently from nosebleeds and that she dislikes the bruises on her skin, especially on her arms. Her GP wonders whether it might be better for her to switch from her VKA to a NOAC as randomised controlled trials showed that NOACs compared to VKAs are at least as
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