Oral anticoagulants
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Unit Supplement 4
June 2025
This edition of check addresses some of the knowledge gaps in the use of oral anticoagulants in general practice to increase general practitioner confidence and support the appropriate use of oral anticoagulants among patients with atrial fibrillation who are at increased risk of stroke.
In Australia, atrial fibrillation contributed to nearly 10% of all deaths in 2022 and is the most common type of recurrent heart arrhythmia affecting adults aged ≥55 years. Moreover, the risk of developing atrial fibrillation doubles with each advancing decade of age, and prevalence is rising.
For many patients, having atrial fibrillation is associated with a substantially increased risk of stroke. Appropriate use of oral anticoagulants can reduce this risk by 64% and the risk of death by 26%. In fact, oral anticoagulation has been the only intervention to improve survival in randomised controlled trials of atrial fibrillation therapy.
Despite their proven benefits, emerging evidence suggests that the use of oral anticoagulants in general practice is suboptimal and as a result, many patients are missing out on potentially life-saving treatment. Australian data from 2018 show that only 55.2% of patients with a high stroke risk had an anticoagulant prescription recorded. A number of factors appear to contribute to this undertreatment including concern over bleeding risk; knowledge and skills gaps regarding who and how to screen for atrial fibrillation; and the appropriate use of anticoagulants for patients with renal impairment or multimorbidity, or who require dual or triple antiplatelet therapy. Variations and lack of guideline consistency have also led to confusion regarding peri- and post-procedural management of oral anticoagulants.
Adequate patient education at the initiation of treatment is crucial. Many patients face competing health priorities or experience treatment fatigue, especially if they are taking multiple medications for other conditions. Lack of understanding of their condition, fear of potential side effects (especially bleeding), and misconceptions about the necessity of treatment have all been reported as reasons why patients discontinue oral anticoagulant therapy.
It is imperative that cases of atrial fibrillation are detected early, that risk assessment tools are used to evaluate stroke risk and that anticoagulation is promptly initiated when appropriate. Prescribers and patients need to better understand the risk–benefit equation of using anticoagulants, and change the assessment of bleeding risk to consideration about how bleeding risk factors can be modified.
At the end of this activity, participants will be able to:
Karen, aged 68 years, presents to your clinic for a repeat prescription for her antihypertensive medication. It has been six months since her last consultation. She reports feeling generally well with occasional knee pain (likely from previously diagnosed osteoarthritis), which she manages with paracetamol as needed.
Buki, aged 72 years, is a regular long-term patient of your practice. You have consulted with him a few times previously but he mostly sees other doctors. He presents today with his wife, who is also a patient at your practice. Buki tells you that, over the past several months, he has been feeling increasingly tired, finding it more difficult to walk places and feeling lightheaded. He is wondering if he is unfit and needs to do more exercise. Buki has a past history of paroxysmal atrial fibrillation, type 2 diabetes, hypertension and chronic kidney disease.
Leila, aged 66 years, is a regular patient. She last attended five months ago for her routine blood pressure prescription. At that visit you noted her blood pressure was 145/90 mmHg and suggested she return in one month to see the practice nurse for another blood pressure check but she did not return. She presents today complaining of ‘heart flutters’.
George, a retired teacher aged 75 years, is a long-term patient at your practice. He has been finding it increasingly difficult to garden and attend lawn bowls due to severe osteoarthritis in his right hip. He has been scheduled for an elective hip replacement.
George has a history of atrial fibrillation and hypertension. He is anxious because the specialist mentioned that he would need to withhold his anticoagulant before surgery. George has come to see you because he is worried about what this means for his stroke risk.
Sofia, aged 80 years, lives in a residential aged care home. You are seeing her as there is concern about frequent bruising and an increasing fear of falling. Sofia has been on warfarin for atrial fibrillation for 15 years. You note that INR monitoring has been inconsistent due to logistical challenges at the residential aged care home, and that recorded levels frequently fluctuate (1.6–3.8).
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Each unit of check comprises approximately five clinical cases, and the choice of cases will cover the broad spectrum of the unit’s topic. Each unit will be led by a GP with an interest and capability in the topic, and they will scope the five different cases for that unit in collaboration with the check team.