Antithrombotic Therapy Prescribed for Patients with Non-Rheumatic Atrial Fibrillation

Abstract

Patients with non-rheumatic atrial fibrillation have a fivefold increased risk of stroke. Warfarin reduces this risk by approximately two thirds, but evidence for benefit from aspirin is less compelling. We assessed whether our current practice reflects the message of the trials. In a retrospective case record study we reviewed notes of 131 patients with atrial fibrillation (AF), mean age 79 (range 53-95) years, admitted to a medical unit (72) or geriatric assessment unit (59). Thirty-two patients had paroxysmal AF. Of 115 patients with nonrheumatic AF, 36 (31%) had one or more recorded contraindication to anti-coagulation. Although 79 patients (69%) had no recorded contraindication to warfarin, only 2 took warfarin and 15 aspirin prior to admission. Ten patients commenced warfarin and 8 aspirin before discharge. Thirty-nine patients (53%) without contraindication, were discharged without antithrombotic therapy. Despite evidence to support anticoagulating patients with non-rheumatic AF, this rarely occurs.

The Utilization of Antithrombotic Prophylaxis for Atrial Fibrillation in a Geriatric Rehabilitation Hospital

“…Whereas 66% (67/102) of our patients had possible contraindications to warfarin, 77% (25/35) of the eligible patients were anticoagulated with warfarin. The use in eligible patients is significantly higher than the rates reported in previous hospital‐based studies 15, 18, 19 and may reflect the fact the the recent trial evidence has been disseminated widely among the physicians at our hospital through specific educational rounds. However, there is still concern in that in an optimal setting for the application of known efficacious therapy, 23% of the patients without contraindications to warfarin were not anticoagulated.…”

“…However, our study sample was enrolled consecutively, and the findings of this study are consistent with data from other recently reported practice audits. For instance, three hospital‐based pattern of practice analyses 15, 18, 19 in the United Kingdom reported that 47 to 53% of patients with atrial fibrillation and without contraindications were not prescribed warfarin or aspirin prophlaxis. Similarly, only 79% of eligible AF patients received warfarin in a population‐based practice audit in Massachusetts 16 …”

Guidelines on anticoagulant treatment in atrial fibrillation in Great Britain: variation in content and implications for treatment

“…None the less treatment varies,13 14 15 16 17 18 19 20 thus providing conditions where valid clinical guidelines may be useful.…”

Why Do Patients With Atrial Fibrillation Not Receive Warfarin?

“…Despite this conclusive evidence of efficacy, several studies have shown that "realworld" use of warfarin in patients with AF is suboptimal. [12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27] The reasons for this low use are unclear, despite the availability of multiple physician surveys investigating the barriers to the prescription of warfarin. 15,17,[28][29][30][31][32][33][34] Our purpose is to review the evidence of the widespread underuse of warfarin therapy in AF as well as the proposed reasons (barriers) for underuse.…”