General practice-related variation in oral anticoagulant treatment of atrial fibrillation: a nationwide cohort study

Dear Editor,

The recent BJGP Open and BJGP studies by Laugesen et al and Jones et al demonstrate the central role of primary care in atrial fibrillation (AF) management, revealing significant practice-level variation in anticoagulation and the complex interplay between AF, heart failure, and stroke risk.^1,2 These findings raise an important question: could implementation challenges be partly related to the absence of primary care perspectives in guideline development?

While specialist expertise in electrophysiology and interventional cardiology is essential for technical recommendations, the voice of primary care remains largely absent from major AF guidelines. The 2024 ESC Guidelines were developed by a task force predominantly composed of cardiologists and cardiac surgeons, despite explicitly acknowledging that AF 'has a broad impact on all health services across primary and secondary care.'³ Similarly, the 2023 ACC/AHA/ACCP/HRS Guideline Writing Committee included no family medicine or general practice representation among its voting members.⁴

This matters because guidelines developed without primary care input may inadvertently create implementation barriers—complex algorithms less suited to time-constrained consultations, specialist-centric treatment sequences, or assumptions about resource availability that do not reflect community practice realities. The ESC itself acknowledges that 'the actual implementation of guidelines is often poor.'³

We propose that future AF guideline committees include meaningful representation from practicing GPs as full voting members. Their perspective is essential to ensure recommendations are implementable where most AF care actually occurs.

References

1. Laugesen IG, Vestergaard CH, Paust A, et al. General practice-related variation in oral anticoagulant treatment of atrial fibrillation: a nationwide cohort study. BJGP Open 2025; 9(2): BJGPO.2024.0197. DOI: 10.3399/BJGPO.2024.0197.

2. Jones NR, Smith M, Lay-Flurrie S, et al. Stroke incidence in heart failure and atrial fibrillation: a population-based retrospective cohort study. Br J Gen Pract 2025; 75(753): e258–e265. DOI: 10.3399/BJGP.2024.0470

3. Van Gelder IC, Rienstra M, Bunting KV, et al. ESC Scientific Document Group. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Developed by the task force for the management of atrial fibrillation of the European Society of Cardiology (ESC), with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Endorsed by the European Stroke Organisation (ESO). Eur Heart J 2024; 45(36): 3314–3414. DOI: 10.1093/eurheartj/ehae176

4. Joglar JA, Chung MK, Armbruster AL, et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149(1): e1–e156. DOI: 10.1161/CIR.0000000000001193