Attitudes of physicians regarding anticoagulation for atrial fibrillation: a systematic review

Abstract

Background: the efficacy of warfarin for prevention of stroke in patients with atrial fibrillation (AF) is well established, but many people with AF who would benefit from warfarin are not receiving it. This systematic review aims to determine physicians' attitudes to the prescription of warfarin for AF, and identify reasons for its underuse.

Methods: an electronic search of MEDLINE (1950-present), EMBASE (1980-present), CINAHL (1994-present), PsycINFO (1987-present) and Web of Knowledge (1970-present) was performed in November 2010 to identify all studies which addressed, via survey, physicians' attitudes regarding anticoagulation for patients with AF.

Results: a total of 1,375 citations were identified. Of these citations, 44 full text studies were obtained for scrutinisation; 14 of these studies were rejected leaving 30 studies which were included in the review. All included studies were cross-sectional surveys and addressed physicians' opinions of anticoagulation in AF as a primary or secondary aim. Increasing age, increased bleeding risk, previous bleeds, falls risk, co-morbidities and ability to comply with treatment influenced whether physicians would prescribe anticoagulation for AF.

Conclusion: physicians are reticent to recommend warfarin for elderly patients in AF, despite evidence of increased benefit in these patients compared with younger patients. Risk of falls and previous bleeding were also shown to be disproportionate barriers to warfarin prescription. Further studies are required to determine how best to overcome these perceived barriers to appropriate anticoagulation.