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QUARTERLY FOCUS ISSUE: PREVENTION/OUTCOMES: QUALITY OF CARE

Quality of Care for Atrial Fibrillation Among Patients Hospitalized for Heart Failure

Jonathan P. Piccini, MD^_*, Adrian F. Hernandez, MD, MHS^_*,_*, Xin Zhao, PhD^_*, Manesh R. Patel, MD^_*, William R. Lewis, MD, Eric D. Peterson, MD, MPH^_*, Gregg C. Fonarow, MD Get With The Guidelines Steering Committee and Hospitals

^_* Duke Clinical Research Institute, Durham, North Carolina
MetroHealth Campus, Case Western Reserve University, Cleveland, Ohio
University of California Los Angeles Medical Center, Los Angeles, California

Manuscript received January 19, 2009; revised manuscript received March 24, 2009, accepted April 3, 2009.

^_* Reprint requests and correspondence: Dr. Adrian F. Hernandez, Duke Clinical Research Institute, P.O. Box 17969, Durham, North Carolina 27715 (Email: adrian.hernandez{at}duke.edu).

Objectives: This study sought to examine quality of care and warfarin use at discharge in patients with atrial fibrillation (AF) and heart failure (HF).

Background: Atrial fibrillation is common in HF, and national guidelines recommend discharge on warfarin for stroke prophylaxis. However, the frequency and factors associated with the guideline adherence are poorly described.

Methods: We analyzed 72,534 HF admissions from January 2005 through March 2008 at 255 hospitals participating in the American Heart Association's Get With The Guidelines HF program. Multivariable logistic regression was used to identify independent factors associated with warfarin use at discharge.

Results: In this HF population, 20.5% (n = 14,901) had AF on admission, whereas another 13.7% (n = 9,918) had a prior history of AF but were in a regular rhythm at admission. Contraindications to warfarin therapy were documented in 9.2%. Among eligible HF patients without contraindications, the median prevalence of warfarin therapy at discharge was 64.9% (interquartile range 55.5 to 73.4) and did not improve during the 3.5 years of study. After adjustment, major factors associated with no warfarin use at discharge included increasing age, nonwhite race, anemia, and treatment in the south. Warfarin use also varied inversely with CHADS₂ (congestive heart failure, hypertension, age >75, diabetes, and prior stroke or transient ischemic attack) risk (70.9% to 59.5% for CHADS₂ score 1 to 6, p < 0.0001).

Conclusions: Guideline-recommended warfarin use in patients with AF and HF is less than optimal, has not improved over time, and varies significantly according to age, race, risk profile, region, and hospital site.

Key Words: atrial fibrillation • heart failure • anticoagulation

Abbreviations and Acronyms   ACC/AHA = American College of Cardiology/American Heart Association   AF = atrial fibrillation   GWTG = Get With The Guidelines   HF = heart failure   HR = heart rate   IQR = interquartile range   LVEF = left ventricular ejection fraction

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