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.

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

The current practice of stroke prevention was assessed among UK general practitioners (GPs) using a postal questionnaire. A random sample of 583 GPs (response rate 60%) in practice throughout the UK was examined. Main outcomes were the reported practice in the identification of stroke risk, management of hypertension, and use of other interventions (particularly aspirin treatment) to reduce the risk of stroke. Most respondents (451, 77%) reported that they specifically identified patients at high risk of stroke. However, of these only 301 (67%) used more than one major risk factor to do this and less than one-third used either age or pre-existing cardiovascular disease as an indicator. Thresholds for drug treatment of hypertension increased markedly with patient age with only 68%, 23% and 9% of respondents reporting treating elevated systolic, diastolic and isolated systolic pressures respectively, in accord with the British Hypertension Society (BHS) guidelines for patients aged 70-79 years. Thresholds for blood pressure (BP) treatment in older patients did not differ by region but were higher among respondents who had been in general practice for more than 10 years. The value of aspirin in preventing stroke in patients with pre-existing cardiovascular disease was recognized by almost all (560, 96%) respondents. The results suggest that there is scope for increasing the benefits of stroke prevention in primary care, by focusing on the management of patients at high absolute risk, in whom the greatest treatment benefits are likely to be obtained.

Identification and management of stroke risk in older people: a national survey of current practice in primary care

With patients demanding a greater role in the clinical decision-making process, many researchers are developing and disseminating decision aids for various medical conditions. In this article, we outline the essential elements in the development and evaluation of a decision aid to help patients with atrial fibrillation choose, in consultation with their physicians, appropriate antithrombotic therapy (warfarin, aspirin, or no therapy) to prevent stroke. We also outline possible future directions regarding the implementation and evaluation of this decision aid. This information should enable clinicians to better understand the role that decision aids may have in their interactions with patients.

/pdf/development-of-a-decision-aid-for-patients-with-atrial-4ky50k5esi.pdf

Development of a Decision Aid for Patients with Atrial Fibrillation Who Are Considering Antithrombotic Therapy

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.

EDrrOR,-I am concerned about the potential widespread use of warfarin in asymptomatic atrial fibrillation encouraged by recent articles. Philip MW Bath and colleagues assert that overwhelming evidence from trials suggests that this treatment profoundly reduces strokes, carries small risks of bleeding, and is cost effective. I am sceptical; these trials have to be scrutinised closely and compared with real life. Patients enrolled in these trials were carefully screened for the slightest characteristics that might place them at any risk of bleeding and were more likely to be more compliant than average. The Veterans Affairs stroke prevention in nonrheumatic atrial fibrillation study excluded 7444 out of 7982 eligible patients; 6-7% were entered.2 The stroke prevention in atrial fibrillation study initially excluded 17046 eligible patients.' Of the 1330 entered, 703 were considered to be ineligible; only 3-4% were entered. Although atrial fibrillation is more common with advancing age,4 four of the five trials were in younger patients at lower risk. Only one trial was in older patients5; in this study the numbers of events (thromboses and bleeding) were identical in all groups. Despite careful patient selection there were more side effects and noncompliance with warfarin. Though warfarin has led to fatal bleeding, it may not reduce the incidence of major strokes as shown below. I have analysed the data in three trials that have detailed the severity of strokes.23' The results are striking (table). No doubt warfarin reduced the incidence of transient ischaemic attacks and minor non-disabling strokes, but none of the trials showed that the incidence of fatal and disabling strokes was reduced beyond statistical doubt. This reduction in mild strokes has been achieved neither safely nor cheaply. A Canadian study showed an annual rate of fatal or major bleeding of2% despite excluding 94% of eligible patients.6 A complication rate exceeding 1-3% is estimated to increase costs.7 The incidence and severity ofbleeding in ordinary clinical practice is probably even higher. The ratio of risk to benefit will probably also increase with time beyond the

https://www.bmj.com/content/bmj/307/6917/1492.2.full.pdf

L Dow

Papers

Anticoagulation in patients with atrial fibrillation. Underuse of warfarin is multifactorial.