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Physicians' Fears Often Unfounded

Malcolm Man-Son-Hing, MD, MSc; Andreas Laupacis, MD, MSc

Arch Intern Med. 2003;163:1580-1586.

Background  Many studies have documented the underuse of anticoagulant (ie, warfarin sodium) therapy as stroke prophylaxis in older persons with atrial fibrillation. Failure to prescribe anticoagulant agents to these patients is often due to physicians' perceiving the risk of major bleeding as unacceptably high because of the presence of such clinical risk factors as hypertension, falls, a history of gastrointestinal tract bleeding, and lack of assurance about compliance.

Objectives  To critically appraise whether the presence of additional clinical factors that increase the risk of bleeding affects the chance of anticoagulant-related hemorrhage, and to develop an approach to the use of anticoagulant agents in older patients with atrial fibrillation who have any of these factors.

Methods  Systematic MEDLINE literature search from January 1966 to March 2002.

Results  Many of the factors that are purported to be barriers to anticoagulant therapy in older persons with atrial fibrillation probably should not influence the choice of stroke prophylaxis in these patients. These include previous episodes of upper gastrointestinal tract bleeding, predisposition to falling, and old age in itself. For some other factors, such as alcoholism, participation in activities that predispose to trauma, the presence of a bleeding diathesis or thrombocytopenia, and noncompliance with monitoring, there is little or conflicting evidence about their effect on anticoagulant-related bleeding. However, they should be considered in the clinical decision-making process.

Conclusions  For many older patients with atrial fibrillation, physicians' fears of the risk of bleeding in association with anticoagulant therapy are often exaggerated and unfounded. Therefore, the salient issue in selecting older patients with atrial fibrillation for anticoagulation is accurately estimating their stroke risk, with bleeding risk during anticoagulation being a lesser issue, relevant to only a few patients.

From the Clinical Epidemiology Program, Ottawa Health Research Institute; Geriatric Assessment Unit, Ottawa Hospital; Division of Geriatric Medicine, University of Ottawa; and Institute on Health of the Elderly, Sisters of Charity Ottawa Health Service; Ottawa (Dr Man-Son-Hing); and the Institute for Clinical Evaluative Sciences and Faculty of Medicine, University of Toronto, Toronto (Dr Laupacis); Ontario, Canada. The authors have no relevant financial interest in this article.

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