Age and Ageing, Vol 28, 441-446, Copyright © 1999 by British Geriatrics Society
GE Mead, JM Wardlaw, SC Lewis, M McDowall and MS Dennis
INTRODUCTION: Anticoagulants and anti-platelet drugs have been shown in
randomized trials to reduce the risk of stroke in patients with atrial
fibrillation (AF). We therefore investigated their use in patients known to
be in AF before a stroke, transient ischaemic attack (either cerebral or
ocular) or retinal artery occlusion to assess the influence of trials on
clinical practice. METHODS: Inpatients and outpatients with acute stroke,
transient ischaemic attack or retinal artery occlusion were prospectively
identified by a stroke physician from 1990 to 1997. The presence or absence
of AF before the vascular event, and prior use of anticoagulant and
anti-platelet drugs were recorded at the time of the assessment and
verified using information from general practitioner and hospital case
notes. RESULTS: Of 1934 patients with stroke or retinal artery occlusion,
191 (10%) were in AF before their ischaemic event. Anticoagulants had been
used in 40 (21%) of these, but only in 32 (2%) of the 1743 patients in
sinus rhythm [odds ratio (OR) 14.2, 95% confidence interval (CI) 8.6-23.2].
Anti-platelet drugs had been used in 62 (32%) of those with AF compared
with 500 (30%) of those in sinus rhythm (OR 1.2, 95% CI 0.9-1.64). Of the
161 patients in AF without contraindications to anticoagulants, only 36
(22%) were taking them. Although there was a statistically significant
increase in anticoagulant use from 8% in 1990 to 23% in 1996, this could be
explained solely by a fall in the age of the patients referred to our
hospital. CONCLUSION: Anticoagulation is probably under-used in AF. We
found no conclusive evidence that anticoagulation trials have influenced
clinical practice. This raises issues about the dissemination and
implementation of trial results.
ARTICLES
The influence of randomized trials on the use of anticoagulants for atrial fibrillation
Department of Clinical Neurosciences, University of Edinburgh, Western General Hospital, UK. GEM@skull.dcn.ed.ac.uk
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