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survey reveals gaps in stroke prevention measures

Over a third of GPs are unlikely to meet the Government's deadline requiring practices to demonstrate that they can identify and treat patients at risk of stroke, according to a new survey published today by AntiCoagulation Europe.

GPs voiced a need for local protocols, computer and nursing support in order to be able to meet these April 2004 targets set by Standard 5 of the National Service Framework for Older People.

Stroke is a devastating yet preventable condition which imposes a huge medical and cost burden on the NHS, stroke patients, their families and society in general. The risk of having a stroke is increased with certain medical conditions, such as atrial fibrillation (AF).

GPs surveyed identified AF to be a key risk factor for stroke, second only to hypertension. In patients with AF, treatment with the anticoagulant warfarin has been shown to reduce the incidence of stroke by 68% (compared to 20% with aspirin) and hence guidelines (ref) recommend warfarin as the treatment of choice for patients with moderate to high risk of stroke. Although highly effective, warfarin treatment is complex to deliver as it requires close monitoring and titration, and interacts with food and other common medicines. Over 35% of the GPs questioned prescribe aspirin as their only preventative action, rather than recommending or referring for warfarin. 20% of GPs reported that up to 1 in 10 AF patients do not receive any form of anticoagulation therapy.

When questioned why warfarin is not initiated, the survey highlighted GP fears about warfarin treatment - 72% cited the dangers of poorly controlled warfarin or the risks of bleeding. In a further 26% of patients, warfarin is not prescribed because of contraindications with other diseases or medications.

Eve Knight of AntiCoagulation Europe said: "Whilst GPs recognise the importance of AF, services to support close monitoring of anticoagulation therapy are overstretched. There is a clear need for localised services and protocols within primary care to provide security that the benefits of anticoagulation in high risk patients outweigh any risks and help GPs meet targets in quality care."

Mark Davies, a specialist GP with an interest in stroke prevention agreed, adding: "Aspirin is often prescribed in patients with AF who are at high risk of stroke, because we are trying to do something to help, despite the fact we know it is not the most effective treatment for these people. It's usually the patients who have other conditions that are most at risk of stroke and in the greatest need of effective anticoagulation, yet it is these patients that we are often not able to recommend warfarin."

Atrial fibrillation (AF) is a fast and erratic heart beat caused by irregular signals from the heart's time (sino-atrial node). The risk of stroke in AF is related to the heart's irregular rhythm, which increases the chances of blood pooling and forming a clot. Conditions such as hypertension, diabetes, heart failure, or left ventricular dysfunction increase the risk of AF.