Intended for healthcare professionals


Barriers to using warfarin in non-valvular atrial fibrillation

BMJ 2006; 332 doi: (Published 02 February 2006) Cite this as: BMJ 2006;332:303
  1. Melina Gattellari, research fellow (Melina.Gattellari{at},
  2. Nicholas A Zwar, director,
  3. John M Worthington, senior staff specialist in neurology,
  4. Sandy Middleton, professor of nursing
  1. General Practice Unit, School of Public Health and Community Medicine, University of New South Wales, Kensington, NSW 2052, Australia
  2. General Practice Unit, School of Public Health and Community Medicine, University of New South Wales, Kensington, NSW 2052, Australia
  3. Liverpool Health Service. Locked Bag 7017, Liverpool, NSW 1871
  4. School of Nursing (NSW), ACU National, PO Box 968, North Sydney, NSW 2059

    EDITOR—Anticoagulation is underused in the treatment of non-valvular atrial fibrillation. Choudhry et al show that adverse outcomes from anticoagulation have greater influence on its management than occurrences of avoidable ischaemic stroke.1 They speculate that this result arises from undue fear or concern about adverse consequences of anticoagulation.

    We are conducting a representative national survey of 1000 Australian general practitioners, addressing how fear of anticoagulation affects management of non-valvular atrial fibrillation. Our preliminary findings indicate that aversion to the risk of intracranial haemorrhage is substantial. Doctors are overly cautious in prescribing anticoagulation where there is a perceived risk of major and even minor bleeding even when the benefits of anticoagulation outweigh the risks.

    In 207 early responses, 95 doctors reported the experience of an ischaemic stroke in their patients with non-valvular atrial fibrillation without anticoagulation. Only 27 reported experiencing an intracranial haemorrhage in such patients receiving anticoagulants. Over half of general practitioners (112) expected to feel equal responsibility for either an intracranial haemorrhage in a patient taking anticoagulants or a fatal or disabling ischaemic stroke without anticoagulation. Nearly a fifth (40) would feel more responsible for an intracranial haemorrhage.

    When asked to select treatment for a hypothetical patient with non-valvular atrial fibrillation at “high” risk of stroke,2 nearly three quarters of doctors (150) would appropriately select warfarin. A perceived risk of bleeding markedly reduced selection of warfarin even when the risk of bleeding was acceptable, according to best available evidence.3 4 In the presence of a risk of minor falls that would not contraindicate anticoagulation,3 fewer than half of doctors (96) selected warfarin. Only just over a quarter (58) would give anticoagulants to a patient at high risk of stroke with a history of recurrent nosebleeds. Only a fifth of doctors (42) would give anticoagulants to such a patient with a previously treated, bleeding peptic ulcer.

    Implementing evidence based management of non-valvular atrial fibrillation is proving difficult, and the potential to reduce the risk of stroke is yet to be fully realised.5 Our preliminary findings support the assertion by Choudhry et al, that the under-prescribing of anticoagulants for atrial fibrillation has a profound psychological dimension. Any strategy to improve the evidence based management of non-valvular atrial fibrillation will need to tackle the excessive concerns that clinicians have about anticoagulation. We need to reduce anxiety about “acts of commission” in the management of non-valvular atrial fibrillation.


    • Competing interests None declared.


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