BACKGROUND: The prevalence of atrial fibrillation (AF) increases dramatically with advancing patient age, and, as a result, this condition is common in persons residing in the long-term care setting.



OBJECTIVES: To assess the knowledge and attitudes of physicians regarding the use of warfarin for stroke prevention in patients with atrial fibrillation in long-term care facilities.



METHODS: We surveyed physicians actively providing primary care to older patients in 30 long-term care facilities located in New England, Quebec, and Ontario. Physicians were requested to complete a structured questionnaire about use of warfarin therapy for stroke prevention in patients with AF residing in long-term care facilities. The questionnaire included two clinical scenarios designed to provide substantial contrasts in patient characteristics including underlying comorbidity, functional status, bleeding risk, and stroke risk.



RESULTS: A total of 269 physicians were asked to participate in the survey, and 182 (67.7%) completed the questionnaire between February 1, 1995, and July 31, 1995. Only 47% of respondents indicated that the benefits of warfarin therapy “greatly outweigh the risks” in this setting; the remainder of physicians indicated that benefits only “slightly outweigh the risks” (34%) or that risks “outweigh benefits” (19%). The most frequently cited contraindications to warfarin use were: excessive risk of falls (71%), history of gastrointestinal bleeding (71%), history of other non-central nervous system bleeding (36%), and history of cerebrovascular hemorrhage (25%). Among the 164 physicians who reported using the international normalized ratio to monitor warfarin therapy, 27% indicated a target range with a lower limit less than 2, 71% indicated a target range between 2 and 3, and 2% indicated an upper limit greater than 3. Among respondents who answered questions about the two clinical scenarios, estimates of the risk of a stroke without warfarin therapy and the risk of an intracranial hemorrhage with therapy varied widely.



CONCLUSIONS: Our findings suggest that many uncertainties surround the decision to prescribe warfarin to patients with AF in the long-term care setting, as well as questions about the appropriate intensity of this treatment when it is prescribed. Concerns about the risks of bleeding appear to prevail over stroke prevention when physicians make such prescribing decisions.

Physician attitudes concerning warfarin for stroke prevention in atrial fibrillation: results of a survey of long-term care practitioners.

Seven randomized trials published in the last six years have shown that warfarin reduces the risk of ischaemic strokes and death in patients with atrial fibrillation The annual rates of major bleeding episodes in all these trials were low and, as a result, doctors in primary and secondary care are being encouraged to consider using warfarin for patients with atrial fibrillation unless there are obvious contraindications However, the populations used in these studies were highly selected and rigorously monitored throughout the trial period to minimize the risk of bleeding in a way which probably could not be expected in routine primary care Although the rates of major bleeding episodes were uniformly low, the rates of minor bleeding episodes were much higher and these could impact substantially on patients' views of the treatment and on the workload of the primary care team Evidence is now at hand which allows the stratification of risk in patients with atrial fibrillation which should enable those who are at greatest risk to be considered for this form of treatment Patients may develop risk factors over time which could render them unsuitable for continuation of warfarin therapy The general practitioner is centrally placed to make the decision about initiating or continuing treatment or indeed stopping it Several models for decision making in warfarin treatment from primary and secondary care are proposed

Use of warfarin in non-rheumatic atrial fibrillation: a commentary from general practice.

Background: Decision aids have been shown to be useful in selected situations to assist patients in making treatment decisions. Important features such as the format of decision aids and their graphic presentation of data on benefits and harms of treatment options have not been well studied. Methods: In a randomized trial with a 3 × 2 factorial design, we investigated the effects of decision aid format (decision board, decision booklet with audiotape, or interactive computer program) and graphic presentation of data (pie graph or pictogram) on patients9 comprehension and choices of 3 treatments for anticoagulation, identified initially as “treatment A” (warfarin), “treatment B” (acetylsalicylic acid) and “treatment C” (no treatment). Patients aged 65 years or older without known atrial fibrillation and not currently taking warfarin were included. The effect of blinding to the treatment name was tested in a before–after comparison. The primary outcome was change in comprehension score, as assessed by the Atrial Fibrillation Information Questionnaire. Secondary outcomes were treatment choice, level of satisfaction with the decision aid, and decisional conflict. Results: Of 102 eligible patients, 98 completed the study. Comprehension scores (maximum score 10) increased by an absolute mean of 3.1 ( p p Interpretation: The decision aid led to significant improvement in patients9 knowledge regardless of the format or graphic representation of data. Revealing the name of the treatment options led to significant shifts in declared treatment preferences.

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Influence of decision aids on patient preferences for anticoagulant therapy: a randomized trial

A repeat postal questionnaire of British otolaryngologists has been carried out to assess changes in their practice of obtaining informed consent. The previously reported high level of good practice is maintained. Currently informed consent is more often obtained in outpatients or the preadmission clinic than it was in 1991. Consultants and specialist registrars are more involved in this process. Although there is little evidence given to support a persistent increase in a defensive approach towards gaining informed consent, there is some change in the reporting of surgical complications that may reflect an increased awareness of the concept of 'material risk'.

Informed consent: British otolaryngologists surveyed.

Atrial fibrillation is the most common sustained cardiac dysrhythmia treated in North America and Europe. As such, it is one of the current epidemics in cardiovascular disease. Findings from the AFFIRM (Atrial Fibrillation Follow-up: Investigation of Rhythm Management) and RACE (RAte Control versus Electrical cardioversion for persistent atrial fibrillation) clinical trials are presented and the current evidence for the management of atrial fibrillation using anticoagulation, rate-control, and rhythm-control strategies is outlined. Implications for nurses are discussed including physiologic and psychosocial interventions.

Implications for nursing care of patients with atrial fibrillation: lessons learned from the AFFIRM and RACE studies.

heterogeneous group, such a blanket statement as the above must be intolerable. In terms of the risk of bleeding, the Boston area anticoagulation trial, which included subjects aged over 80, reported two deaths from fatal haemorrhage out of 212 patients treated with warfarin.2 At the same time the risk reduction for stroke was 86%. In a study of spontaneous intracranial haemorrhage Schutz et al reported only two cases out of 42 as being due to treatment with warfarin.4 Tabibian, in an evaluation of acute gastrointestinal bleeding in patients aged 40-89 given anticoagulant drugs, reported that age, duration of anticoagulation, degree of prolongation of prothrombin time, and presence or absence of gastrointestinal symptoms were of no value in predicting the risk ofbleeding.5 Thus the decision about anticoagulation should be based on a holistic evaluation of the patient and not on age alone.

https://www.bmj.com/content/bmj/307/6917/1494.1.full.pdf

K N Davies

Papers

Anticoagulation in patients with atrial fibrillation. Doctors reluctant despite evidence.