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Cox-2 'turmoil' as rofecoxib return gets green light

Patients at the highest risk of stroke are often missing out on warfarin therapy, concludes an audit of GP management of atrial fibrillation.

The GP research leader warned that practices were not targeting warfarin effectively after finding no relationship between a patient's level of risk and the likelihood they were receiving treatment.

But anticoagulation experts said GPs faced a 'delicate balancing act' over warfarin because of the dangers of the drug in some patients.

Some 42.6 per cent of men at moderate risk, 43.1 per cent at high risk and 51.7 per cent at very high risk were taking warfarin, according to the study, published in the Journal of Public Health (March).

In women, the proportion was 40.0 per cent for those at moderate risk, but just 33.5 per cent at high risk and 32.5 per cent at very high risk.

Overall, over half of patients with atrial fibrillation were not receiving warfarin despite having no recorded contraindications. A fifth were not receiving warfarin or

aspirin.

Lead researcher Dr Simon de Lusignan, senior lecturer in primary care informatics at St George's Hospital Medical School and a GP in Guildford, said: 'Compelling evidence about the benefits of warfarin is not being translated into practice. If you stratify people with atrial fibrillation according to risk of stroke, those most at risk won't necessarily be on warfarin.'

He urged GPs to search practice records and prioritise patients at highest risk.

'We found it was feasible to go into GP computer data and do searches to find people at risk,' he said. 'It's a tool to help raise quality standards. When you get collective data it's much more powerful.'

Dr Jonathan Mant, senior lecturer in the department of primary care at the University of Birmingham, agreed practice audits were a good idea. But he warned that it was difficult for GPs to balance the risks and benefits of warfarin, particularly in elderly patients.

'Within atrial fibrillation and over-75s we don't know whether the balance of risks and benefits is such that people should be on it or not. But my impression is that many more doctors are prescribing it now than were three or four years ago,' he said.

By Emma Wilkinson

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