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CMAJ • January 11, 2000; 162 (1)
© 2000 Canadian Medical Association or its licensors

Letters
Correspondance

Anticoagulant prophylaxis against stroke

John Sehmer

Family physician; Vancouver, BC

Jaime Caro and colleagues are to be congratulated for their study confirming the beneficial effect of anticoagulants to prevent stroke in atrial fibrillation.1 In the same issue Stuart Connolly asks why so many eligible patients are not receiving anticoagulant therapy.2 I would suggest the following possible reasons.

First, patients may be reluctant to go to a testing laboratory on a regular basis. They may also be concerned about the restrictions the use of blood thinners may impose on their lifestyle.

Second, there is the issue of informed consent. Using the results of the study by Caro and colleagues, a diligent physician might explain to a patient that the risk of stroke in individuals taking warfarin is 2.3 per 100 person-years as opposed to 6.7 per 100 person-years in the no-treatment group and that the hazard rate from bleeding is 3.4 per 100 person-years in the warfarin group versus 1.9 per 100 person-years in the no-treatment group. The patient might assume that taking warfarin would mean going from the frying pan into the fire.

The third reason is physician reluctance. Connolly makes no mention of the increased workload anticoagulant therapy places on the treating physician and his or her staff. Whenever a patient goes for a blood test, the international normalized ratio (INR) results are typically phoned into the physician's office. The physician must then modify the dose as required and notify the patient of any changes. This requires several phone calls and can be a major source of anxiety (and possible medicolegal liability) when, for whatever reason, the doctor's office is unable to reach the patient to make the required medication changes. Admittedly, in BC physicians do get paid the princely sum of $2.73 for providing this service.

References

  1. Caro JJ, Flegel KM, Orejuela ME, Kelley HE, Speckman JL, Migliaccio-Walle K. Anticoagulant prophylaxis against stroke in atrial fibrillation: effectiveness in actual practice. CMAJ 1999;161(5):493-7.[Abstract/Free Full Text]
  2. Connolly SJ. Preventing stroke in atrial fibrillation: Why are so many eligible patients not receiving anticoagulant therapy? [editorial] CMAJ 1999;161(5):533-4.[Free Full Text]




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