USE OF WARFARIN IN NONRHEUMATIC ATRIAL-FIBRILLATION - A COMMENTARY FROM GENERAL-PRACTICE

Seven randomized trials published in the last six years have shown tha t 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 pa tients with atrial fibrillation unless there are obvious contraindicat ions. However, the populations used in these studies were highly selec ted and rigorously monitored throughout the trial period to minimize t he risk of bleeding in a way which probably could not be expected in r outine primary care. Although the rates of major bleeding episodes wer e uniformly low, the rates of minor bleeding episodes were much higher and these could impact substantially on patients' views of the treatm ent and on the workload of the primary care team. Evidence is now at h and which allows the stratification of risk in patients with atrial fi brillation which should enable those who are at greatest risk to be co nsidered for this form of treatment. Patients may develop risk factors over time which could render them unsuitable for continuation of warf arin 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 prim ary and secondary care are proposed.