Barriers to Anticoagulation in Patients With Atrial Fibrillation

Abstract

HomeStrokeVol. 39, No. 1Barriers to Anticoagulation in Patients With Atrial Fibrillation Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBBarriers to Anticoagulation in Patients With Atrial FibrillationChanging Physician-Related Factors Deirdre A. Lane, PhD and Gregory Y.H. Lip, MD, FRCPE Deirdre A. LaneDeirdre A. Lane From the Haemostasis, Thrombosis and Vascular Biology Unit, University Department of Medicine, City Hospital, Birmingham, England. Search for more papers by this author and Gregory Y.H. LipGregory Y.H. Lip From the Haemostasis, Thrombosis and Vascular Biology Unit, University Department of Medicine, City Hospital, Birmingham, England. Search for more papers by this author Originally published29 Nov 2007https://doi.org/10.1161/STROKEAHA.107.496554Stroke. 2008;39:7–9Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: November 29, 2007: Previous Version 1 See related article, pages 227–230.Atrial fibrillation (AF) is not a benign cardiac arrhythmia but instead confers a 5-fold increased risk of stroke compared with age-matched people in sinus rhythm.1 AF patients also have a worse outcome after stroke, with elevated mortality and stroke recurrence rates,2 longer hospital stays,3 and lower discharge rates to their own homes.3 Current estimates suggest that AF afflicts ≈2.2 million Americans,4 whereas in the United Kingdom ≈740 000 individuals are thought to have AF,5 with >46 000 new cases being diagnosed each year.6 Given the increasing prevalence of AF and the associated thromboembolic complications, there are significant numbers of patients who require chronic oral anticoagulation (OAC).Current guidelines7,8 recommend that AF patients at moderate to high risk of stroke should be commenced on chronic anticoagulation with a vitamin K antagonist (VKA). These recommendations are based on data from meta-analyses of 13 randomized controlled trials which have demonstrated significant reductions in stroke9,10 and mortality10 with the use of warfarin. Despite the overwhelming evidence of the benefit of warfarin thromboprophylaxis in patients with AF, such therapy remains significantly underused. OAC care varies considerably from country to country and physicians tend to undertreat more than overtreat.11,12 Physicians’ dilemma of whether to prescribe warfarin is reflected in the recent Euro Heart Survey of AF patients, which revealed that only 67% of patients eligible for VKAs were actually prescribed it,13 although actual ‘real-life’ prescription of OAC may be significantly lower than this.So, why are eligible patients with AF not prescribed OAC? Warfarin itself is plagued by a number of inherent problems, the most important being the narrow therapeutic international normalized ratio (INR) window (target INR 2.5, range 2.0 to 3.0) which must be maintained, given that there is an increased risk of hemorrhagic stroke with INRs >3.0 and thromboembolic complications at INRs <2.0.14,15 A recent systematic review revealed that patients who receive long-term OAC achieve a therapeutic INR only 55% of the time.16 Furthermore, even a 10% increase in time out of therapeutic range is associated with an increased risk of mortality and thromboembolic events.17 Warfarin is also influenced by food, alcohol, and drug interactions and requires regular monitoring. Availability of adequate INR monitoring is an important and necessary component in the decision-making process and requires the necessary infrastructure to facilitate this. Consequently, it is not always possible to offer OAC therapy to everyone who is eligible.In the current issue of Stroke, Gattellari and colleagues18 investigated the psychological barriers to the use of anticoagulation in patients with nonvalvular AF among 596 Australian family physicians using a questionnaire, which asked about their experience of patients’ suffering adverse events while on OAC and their ‘anticipated responsibility’ for these events. In addition, physicians were also presented with 8 case histories to assess their likelihood of prescribing OAC and/or antiplatelet treatment.Personal experience of the prescription of warfarin influenced physicians’ feelings of ‘responsibility’ for strokes or intracranial hemorrhage, a finding supported by previous surveys of physicians’ OAC prescription.12,19,20 Physicians were more likely to feel ‘responsible’ for a stroke occurring while not on OAC than a hemorrhage occurring while on OAC.18 Physicians’ reluctance to prescribe warfarin is often due to a perceived greater risk of bleeding, overestimation of the associated risks, underestimation of the stroke risk, and clinical uncertainty or inexperience of warfarin.The bleeding risk associated with warfarin is an important consideration and is the most common reason among physicians for not prescribing warfarin.12,19–22 Indeed, the survey by Gattellari et al18 revealed that physicians were far less likely to prescribe warfarin when there was an increased risk of bleeding due to history of falls, recent gastrointestinal bleeding, recurrent nose-bleeds, and previous intracranial hemorrhage, despite the patient being at high risk of stroke. Physicians with more years in medical practice were more likely to maintain a preference for warfarin when presented with increased bleeding risk in the case histories, which the authors conclude is a result of experience reducing their fears of OAC. Furthermore, patients are often willing to accept a much higher risk of bleeding for an associated reduction in the risk of stroke compared with physicians.23The following risk factors have been identified as increasing the risk of bleeding in patients taking warfarin: increased age, female sex, hypertension, anemia, previous MI, cerebrovascular disease, concomitant use of antiplatelet therapy, history of previous bleeding, and concomitant medication use.24 Three bleeding risk stratification models have been proposed,24 but complex algorithms and the need for further prospective validation of these systems means that these schemas are not currently widely used but they may be a useful adjunct in the warfarin prescription decision-making process.Increasing age is associated with a reduction in the likelihood of being prescribed warfarin in AF patients22 mainly because of the perception that there is an increased risk of bleeding in older people (due to polypharmacy, comorbidites, increased likelihood of falls, decline in cognitive function, inability to attend for regular INR checks) and second, the lack of data of the risk/benefit profile of warfarin thromboprophylaxis among the elderly from randomized controlled trials. However, the Birmingham Atrial Fibrillation Treatment of the Aged (BAFTA) trial, an RCT comparing dose-adjusted warfarin, with a target INR of 2.5 (range 2.0 to 3.0, compared with 75 mg aspirin, in elderly >75 years), in the primary-care setting, has recently demonstrated that warfarin was associated with a significant reduction in fatal or nonfatal disabling stroke (ischemic or hemorrhage, or significant arterial embolism; OR 0.48, 95% CI, 0.28 to 0.80, NNT 50), with no difference in the risk of significant bleeds (ICH and all other major hemorrhages) between the warfarin and aspirin groups (0.87, 0.43 to 1.73 and 0.96, 0.53 to 1.75 for ICH and all major hemorrhages, respectively).25 These are extremely important data, given that the prevalence of AF and stroke events is greater among the elderly and these are the people more likely to benefit from OAC but less likely to receive it.Perhaps the most alarming result from the survey by Gattellari et al18 is that as the bleeding risk and stroke risk increased in the case scenarios, the likelihood of prescribing warfarin decreased dramatically because of the uncertainty and lack of knowledge of the risk-benefits of warfarin displayed by a large proportion of GPs. Despite obvious and multiple risk factors for stroke, guidelines for the antithrombotic management of AF were not adhered to. This finding is supported by the Euro Heart Survey on AF13 which showed that the prescription of OAC was quite high over all stroke-risk categories, meaning that many AF patients at low-risk of stroke were exposed to an increased risk of bleeding, the inconvenience of regular INR monitoring, and lifestyle restrictions unnecessarily13 and that known risk factors for stroke did not promote OAC prescription in multivariate analyses.13Physicians may not adhere to the guidelines because they are either not aware of them or their knowledge of them is poor, or alternatively it may be because the guidelines are deficient in terms of evidence-based information (eg, the risks associated with the type of AF, uncontrolled hypertension, and ‘combination’ therapy for patients with vascular disease). Furthermore, the complexity of some risk stratification schemes and the importance of certain stroke risk factors may limit their applicability and physicians knowledge of them, although the CHADS2 scheme, for example, is short and the acronym denotes the risk factors and the weight of their importance. We echo the recommendation of the Euro Heart survey on AF13 for one standardized and simple-to-use stroke risk stratification scheme to facilitate appropriate and wider prescription of OAC therapy in AF patients.In addition to physician-reluctance, there are patient-related barriers to warfarin prescription, the most pertinent of which are patients’ often limited knowledge about the disease, its treatment, and the risk-benefit ratio of warfarin thromboprophylaxis,26 and their preferences for treatment. Patient education and/or self-monitoring of the INR, pictorial representations of the risk and benefits of warfarin, involving the patient in the decision-making process, and consideration of their preferences for treatment have all been shown to increase the likelihood of compliance with associated benefits in outcomes.27There are a number of steps physicians should take when deciding whether to initiate warfarin therapy. First, assess the risk of stroke according to current clinical guidelines7,8 and the associated risk of bleeding individually for each patient. Second, physicians should educate the patient about the need for OAC, the risk and benefits associated with treatment, and the importance of maintaining a therapeutic INR. Third, patient preferences for treatment should be taken into consideration, to ensure compliance. Finally, the risk profile should be reviewed regularly, including detection and optimal management of common risk factors, such as hypertension.28,29 These factors together with the advent of ‘new’ oral anticoagulants will hopefully help to improve the prescription of, and compliance with, OAC among eligible AF patients and reduce stroke rates and the associated morbidity and mortality.The opinions in this editorial are not necessarily those of the editors or of the American Heart Association.DisclosuresNone.FootnotesCorrespondence to Prof Gregory Y.H. Lip, Haemostasis, Thrombosis and Vascular Biology Unit, University Department of Medicine, City Hospital, Birmingham B18 7QH, England. E-mail [email protected] References 1 Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham study. Stroke. 1991; 22: 983–988.CrossrefMedlineGoogle Scholar2 Marini C, De Santis F, Sacco S, Russo T, Olivieri L, Totaro R, Carolei Al. Contribution of atrial fibrillation to incidence and outcome of ischaemic stroke: results from a population-based study. Stroke. 2005; 36: 1115–1119.LinkGoogle Scholar3 Jorgensen HS, Nakayama H, Reith J, Raaschou HO, Olsen TS. Acute stroke with atrial fibrillation: The Copenhagen Stroke Study. Stroke. 1996; 27: 1765–1769.CrossrefMedlineGoogle Scholar4 Chugh SS, Blackshear JL, Win-Kuang Shen, Hammill SC, Gersh BJ. Epidemiology and natural history of atrial fibrillation: clinical implications. J Am Coll Cardiol. 2001; 37: 371–378.CrossrefMedlineGoogle Scholar5 Dewilde S, Carey IM, Emmas C, Richards N, Cook DG. Trends in the prevalence of diagnosed atrial fibrillation, its treatment with anticoagulation, and predictors of such treatment in UK primary care. Heart. 2006; 92: 1064–1070.CrossrefMedlineGoogle Scholar6 Ruigomez A, Johansson S, Wallander MA, Rodriguez LA. Incidence of chronic atrial fibrillation in general practice and its treatment patterns. J Clin Epidemiol. 2002; 55: 358–363.CrossrefMedlineGoogle Scholar7 ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: full text: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation) Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation. 2006; 114: e257–e354.LinkGoogle Scholar8 National Collaborating Centre for Chronic Conditions. Atrial fibrillation: national clinical guideline for management in primary and secondary care. London: Royal College of Physicians 2006. Available at: http://www.nice.org.uk/guidance/CG36. Search date 2005; primary sources CINAHL, Cochrane, EMBASE, MEDLINE. Accessed June 28, 2007.Google Scholar9 Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med. 2007; 146: 857–867.CrossrefMedlineGoogle Scholar10 Lip GYH, Edwards SJ. Stroke prevention with aspirin, warfarin and ximelagatran in patients with non-valvular atrial fibrillation: a systematic review and meta-analysis. Thrombo Res. 2006; 118: 321–333.CrossrefMedlineGoogle Scholar11 Ansell J, Hollowell J, Pengo V, Martinez-Brotons F, Caro J, Drouet L. Descriptive analysis of the process and quality of oral anticoagulation management in real-life practice in patients with chronic non-valvular atrial fibrillation: the international study of anticoagulation management (ISAM). J Thrombo Thrombolysis. 2007; 23: 83–91.CrossrefMedlineGoogle Scholar12 Bungard TJ, Ghali WA, Teo KK, McAlister FA, Tsuyuki R. Why do patients with atrial fibrillation not receive warfarin? Arch Intern Med. 2000; 160: 41–46.CrossrefMedlineGoogle Scholar13 Nieuwlaat R, Capucci A, Lip GYH, Bertil Olsson S, Prins MH, Nieman FH, Lopez-Sendon J, Vardas PE, Aliot E, Santini M, Crijns HJ; Euro Heart Survey Investigators. Antithrombotic treatment in real-life atrial fibrillation patients: a report from the Euro Heart Survey on Atrial Fibrillation. Eur Heart J. 2006; 27: 3018–3026.CrossrefMedlineGoogle Scholar14 Hylek EM, Go AS, Chang Y, Jensvold NG, Henault LE, Selby JV, Singer DE. Effect of intensity of oral anticoagulation on stroke severity and mortality. N Engl J Med. 2003; 349: 1019–1026.CrossrefMedlineGoogle Scholar15 Levine MN, Raskob G, Beyth RJ, Kearon C, Schulman S. Haemorrhagic complications of anticoagulant treatment: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004; 126 (Suppl. 3): 287S–310S.CrossrefMedlineGoogle Scholar16 van Walraven C, Jennings A, Oake N, Fergusson D, Forster A. Effect of study setting on anticoagulation control: a systematic review and meta-regression. Chest. 2006; 129: 1155–1166.CrossrefMedlineGoogle Scholar17 Jones M, McEwan P, Morgan CL, Peters JR, Goodfellow J, Currie CJ. Evaluation of the pattern of treatment, level of anticoagulation control, and outcome of treatment with warfarin in patients with non-valvular atrial fibrillation: a record linkage study in a large British population. Heart. 2005; 91: 472–477.CrossrefMedlineGoogle Scholar18 Gattellari M, Worthington JM, Zwar NA, Middleton S. Barriers to the use of anticoagulation for non-valvular atrial fibrillation (NVAF): a representative survey of Australian family physicians. Stroke. 2007; 39: 227–230.MedlineGoogle Scholar19 Bungard TJ, Ghali WA, McAlister FA, Buchan AM, Cave AJ, Hamilton PG, Mitchell LB, Shuaib A, Teo KK, Tsuyuki RT. The relative importance of barriers to the prescription of warfarin for nonvalvular atrial fibrillation. Can J Cardiol. 2003; 19: 280–284.MedlineGoogle Scholar20 Beyth RJ, Antani MR, Covinsky KE, Miller DG, Chren M-M, Quinn L, Landefeld CS. Why isn’t warfarin prescribed to patients with non-rheumatic atrial fibrillation? J Gen Intern Med. 1996; 11: 721–728.CrossrefMedlineGoogle Scholar21 Frykman V, Beerman B, Ryden L, Rosenquist M. Management of atrial fibrillation: discrepancy between guideline recommendations and actual practice exposes patients to risk of complications. Eur Heart J. 2001; 22: 1954–1959.CrossrefMedlineGoogle Scholar22 Partington SL, Abid S, Teo K, Oczkowski W, O’Donnell MJ. Pre-admission warfarin use in patients with acute ischaemic stroke and atrial fibrillation; the appropriate use and barriers to oral anticoagulant therapy. Thrombo Res. 2007; 120: 663–669.CrossrefMedlineGoogle Scholar23 Devereaux P, Anderson D, Gardner M, Putnam W, Flowerdew G, Brownell B, Naqpal S, Cox JL. Differences between perspectives of physicians and patients on anticoagulation in patients with atrial fibrillation: observational study. BMJ. 2001; 323: 1218–1222.CrossrefMedlineGoogle Scholar24 Kakar P, Lane D, Lip GYH. Bleeding risk stratification models in deciding on anticoagulation in patients with atrial fibrillation: a useful complement to stroke risk stratification schema. Chest. 2006; 130: 1296–1299.CrossrefMedlineGoogle Scholar25 Mant J, Hobbs FDR, Fletcher K, Roalfe A, Fitzmaurice D, Lip GYH, Murray E; BAFTA investigators; Midland Research Practices Network (MidRec). Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial. Lancet. 2007; 370: 493–503.CrossrefMedlineGoogle Scholar26 Lip GYH, Agnelli G, Thach AA, Knight E, Rost D, Tangelder MJD. Oral anticoagulation in atrial fibrillation: a pan-European patient survey. Eur J Intern Med. 2007; 18: 202–208.CrossrefMedlineGoogle Scholar27 Lane DA, Lip GYH. Anti-thrombotic therapy for atrial fibrillation and patients’ preferences for treatment. Age and Ageing. 2005; 34: 1–3.CrossrefMedlineGoogle Scholar28 Jani B, Bulpitt CJ, Rajkumar C. Blood pressure measurement in patients with rate controlled atrial fibrillation using mercury sphygmomanometer and Omron HEM-750CP deice in the clinic setting. J Hum Hypertens. 2006; 20: 543–545.CrossrefMedlineGoogle Scholar29 Boos CJ, Lip GYH. Targeting the renin-angiotensin-aldosterone system in atrial fibrillation: from pathophysiology to clinical trials. J Hum Hypertens. 2005; 9: 855–859.Google Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited ByBhat A, Khanna S, Chen H, Gupta A, Gan G, Denniss A, MacIntyre C and Tan T (2021) Integrated Care in Atrial Fibrillation, Circulation: Cardiovascular Quality and Outcomes, 14:3, Online publication date: 1-Mar-2021. Sridharan K, Al Banny R, Qader A, Husain A and Qader K (2020) Health-related quality of life in patients receiving oral anti-coagulants: a cross-sectional study, Expert Review of Cardiovascular Therapy, 10.1080/14779072.2020.1760092, 18:5, (309-314), Online publication date: 3-May-2020. Tiew W, Wong V, Tan V, Tan Y and Lee E (2020) A Real-world Experience of the Safety and Efficacy of Non-vitamin K Oral Anticoagulants Versus Warfarin in Patients with Non-valvular Atrial Fibrillation— A Single-centre Retrospective Cohort Study in Singapore, Annals of the Academy of Medicine, Singapore, 10.47102/annals-acadmedsg.2020184, 49:11, (838-847), Online publication date: 30-Nov-2020. Lüscher T (2020) Challenges in atrial fibrillation: detection, alert systems, fibrosis, and infection, European Heart Journal, 10.1093/eurheartj/ehaa153, 41:10, (1063-1066), Online publication date: 7-Mar-2020. Hernandez I, He M, Chen N, Brooks M, Saba S and Gellad W (2019) Trajectories of Oral Anticoagulation Adherence Among Medicare Beneficiaries Newly Diagnosed With Atrial Fibrillation, Journal of the American Heart Association, 8:12, Online publication date: 18-Jun-2019. Russo V, Attena E, Mazzone C, Melillo E, Rago A, Galasso G, Riegler L, Parisi V, Rotunno R, Nigro G and D'Onofrio A (2019) Real-life Performance of Edoxaban in Elderly Patients With Atrial Fibrillation: a Multicenter Propensity Score–Matched Cohort Study, Clinical Therapeutics, 10.1016/j.clinthera.2019.04.041, 41:8, (1598-1604), Online publication date: 1-Aug-2019. Pandya E, Masood N, Wang Y, Krass I and Bajorek B (2016) Impact of a Computerized Antithrombotic Risk Assessment Tool on the Prescription of Thromboprophylaxis in Atrial Fibrillation: Hospital Setting, Clinical and Applied Thrombosis/Hemostasis, 10.1177/1076029616670031, 24:1, (85-92), Online publication date: 1-Jan-2018. Loewen P, Ji A, Kapanen A and McClean A (2017) Patient values and preferences for antithrombotic therapy in atrial fibrillation, Thrombosis and Haemostasis, 10.1160/TH16-10-0787, 117:06, (1007-1022), . Potpara T and Lip G (2015) Oral Anticoagulant Therapy in Atrial Fibrillation Patients at High Stroke and Bleeding Risk, Progress in Cardiovascular Diseases, 10.1016/j.pcad.2015.07.003, 58:2, (177-194), Online publication date: 1-Sep-2015. Liu J, Sylwestrzak G, Barron J, Rosenberg A, White J, Whitney J, Redberg R and Malenka D (2014) Evaluation of practice patterns in the treatment of atrial fibrillation among the commercially insured, Current Medical Research and Opinion, 10.1185/03007995.2014.922061, 30:9, (1707-1713), Online publication date: 1-Sep-2014. Deitelzweig S (2014) Practical Considerations in the Use of Novel Oral Anticoagulants for Stroke Prevention in Nonvalvular Atrial Fibrillation, Cardiovascular Therapeutics, 10.1111/1755-5922.12048, 32:2, (74-81), Online publication date: 1-Apr-2014. Beadles C, Hassmiller Lich K, Viera A, Greene S, Brookhart M and Weinberger M (2013) Patient-Centered Medical Homes and Oral Anticoagulation Therapy Initiation, Medical Care Research and Review, 10.1177/1077558713510563, 71:2, (174-191), Online publication date: 1-Apr-2014. Nicholls S, Brehaut J, Arim R, Carroll K, Perez R, Shojania K, Grimshaw J and Poses R (2014) Impact of stated barriers on proposed warfarin prescription for atrial fibrillation: a survey of Canadian physicians, Thrombosis Journal, 10.1186/1477-9560-12-13, 12:1, Online publication date: 1-Dec-2014. Lang K, Bozkaya D, Patel A, Macomson B, Nelson W, Owens G, Mody S, Schein J and Menzin J (2014) Anticoagulant use for the prevention of stroke in patients with atrial fibrillation: findings from a multi-payer analysis, BMC Health Services Research, 10.1186/1472-6963-14-329, 14:1, Online publication date: 1-Dec-2014. Rosanio S, Keylani A, D'Agostino D, DeLaughter C and Vitarelli A (2014) Pharmacology, benefits, unaddressed questions, and pragmatic issues of the newer oral anticoagulants for stroke prophylaxis in non-valvular atrial fibrillation and proposal of a management algorithm, International Journal of Cardiology, 10.1016/j.ijcard.2014.04.179, 174:3, (471-483), Online publication date: 1-Jul-2014. Tay K, Apostolakis S, Lane D and Lip G (2013) Hemorrhage Risks, Patient Perspectives, and Quality-of-Life Issues Handbook of Oral Anticoagulation, 10.1007/978-1-908517-96-8_4, (41-51), . Lenchus J (2015) Recent Advances in Antithrombotic Therapy for Stroke Prevention in Patients With Atrial Fibrillation, Hospital Practice, 10.3810/hp.2013.02.1007, 41:1, (49-60), Online publication date: 1-Feb-2013. Deedwania P (2013) New Oral Anticoagulants in Elderly Patients with Atrial Fibrillation, The American Journal of Medicine, 10.1016/j.amjmed.2012.10.012, 126:4, (289-296), Online publication date: 1-Apr-2013. Pereira de Sousa L, Burba I, Ruperto C, Lattuada L, Barbone F and Di Chiara A (2013) Vitamin K antagonists in patients with nonvalvular atrial fibrillation, Journal of Cardiovascular Medicine, 10.2459/JCM.0b013e32835dbd58, 14:7, (534-540), Online publication date: 1-Jul-2013. Patel A, Reardon G, Nelson W, Philpot T and Neidecker M (2013) Persistence of Warfarin Therapy for Residents in Long-term Care Who Have Atrial Fibrillation, Clinical Therapeutics, 10.1016/j.clinthera.2013.09.010, 35:11, (1794-1804), Online publication date: 1-Nov-2013. Barry A, Loewen P, de Lemos J and Lee K (2010) Reasons for non-use of proven pharmacotherapeutic interventions: systematic review and framework development, Journal of Evaluation in Clinical Practice, 10.1111/j.1365-2753.2010.01524.x, 18:1, (49-55), Online publication date: 1-Feb-2012. Halperin J and Goyette R (2012) Management of Atrial Fibrillation: Direct Factor IIa and Xa Inhibitors or “Warfarin Shotgun”?, Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine, 10.1002/msj.21346, 79:6, (705-720), Online publication date: 1-Nov-2012. Hickey K (2012) Anticoagulation management in clinical practice: Preventing stroke in patients with atrial fibrillation, Heart & Lung, 10.1016/j.hrtlng.2011.07.008, 41:2, (146-156), Online publication date: 1-Mar-2012. Potpara T, Ličina M, Polovina M, Ostojić M and Ostojić M (2012) Prevention of thromboembolic complications of atrial fibrillation: Current aspects and perspective, Srce i krvni sudovi, 10.5937/siks1202068P, 31:4, (68-76), . Murray S, Lazure P, Pullen C, Maltais P and Dorian P (2011) Atrial Fibrillation Care: Challenges in Clinical Practice and Educational Needs Assessment, Canadian Journal of Cardiology, 10.1016/j.cjca.2010.12.006, 27:1, (98-104), Online publication date: 1-Jan-2011. Yates S (2015) Apixaban for Stroke Prevention in Atrial Fibrillation: A Review of the Clinical Trial Evidence, Hospital Practice, 10.3810/hp.2011.10.918, 39:4, (7-16), Online publication date: 1-Oct-2011. Llisterri Caro J, Polo García J, Martí Canales J and Barrios Alonso V (2011) Nuevas estrategias terapéuticas para la prevención del ictus en pacientes con fibrilación auricular: perspectiva desde atención primaria, SEMERGEN - Medicina de Familia, 10.1016/j.semerg.2011.03.003, 37:7, (352-359), Online publication date: 1-Aug-2011. Kirchhof P, Nabauer M, Gerth A, Limbourg T, Lewalter T, Goette A, Wegscheider K, Treszl A, Meinertz T, Oeff M, Ravens U, Breithardt G and Steinbeck G (2017) Impact of the type of centre on management of AF patients: Surprising evidence for differences in antithrombotic therapy decisions, Thrombosis and Haemostasis, 10.1160/TH11-02-0070, 105:06, (1010-1023), . PRYSTOWSKY E, CAMM J, LIP G, ALLESSIE M, BERGMANN J, BREITHARDT G, BRUGADA J, CRIJNS H, ELLINOR P, MARK D, NACCARELLI G, PACKER D and TAMARGO J (2010) The Impact of New and Emerging Clinical Data on Treatment Strategies for Atrial Fibrillation, Journal of Cardiovascular Electrophysiology, 10.1111/j.1540-8167.2010.01770.x, (no-no) LANE D and LIP G (2010) Anticoagulation for Atrial Fibrillation Patients with CHADS 2 Score of 1 , Journal of Cardiovascular Electrophysiology, 10.1111/j.1540-8167.2009.01687.x, 21:5, (508-510), Online publication date: 1-May-2010. Tay K, Lane D and Lip G (2010) Haemorrhage risks, patient perspectives, and quality-of-life issues Handbook of Oral Anticoagulation, 10.1007/978-1-908517-08-1_4, (35-42), . Kirchhof P, Bax J, Blomstrom-Lundquist C, Calkins H, Camm A, Cappato R, Cosio F, Crijns H, Diener H, Goette A, Israel C, Kuck K, Lip G, Nattel S, Page R, Ravens U, Schotten U, Steinbeck G, Vardas P, Waldo A, Wegscheider K, Willems S and Breithardt G (2009) Early and comprehensive management of atrial fibrillation: Proceedings from the 2nd AFNET/EHRA consensus conference on atrial fibrillation entitled 'research perspectives in atrial fibrillation', Europace, 10.1093/europace/eup124, 11:7, (860-885), Online publication date: 1-Jul-2009. Suárez C and Ruiz-Giménez N (2009) Anticoagulación preventiva: ejemplo de análisis de riesgo/beneficio, Revista Clínica Española, 10.1016/S0014-2565(09)71307-4, 209:4, (157-159), Online publication date: 1-Apr-2009. Sterling J (2008) Recent Publications on Medications and Pharmacy, Hospital Pharmacy, 10.1310/hpj4303-238, 43:3, (238-242), Online publication date: 1-Mar-2008. January 2008Vol 39, Issue 1 Advertisement Article InformationMetrics https://doi.org/10.1161/STROKEAHA.107.496554PMID: 18048849 Originally publishedNovember 29, 2007 Keywordsanticoagulationatrial fibrillationantithromboticsPDF download Advertisement