CLINICAL RESEARCH
Hospitalized Patients With Atrial Fibrillation and a High Risk of Stroke Are Not Being Provided With Adequate Anticoagulation
Albert L. Waldo, MD*,*,
Richard C. Becker, MD ,
Victor F. Tapson, MD ,
Kevin J. Colgan, MA for the NABOR Steering Committee
* Division of Cardiology, Case Western University/University Hospitals of Cleveland, Cleveland, Ohio
Duke Clinical Research Institute, Durham, North Carolina
Department of Pulmonary Medicine, Duke University Medical Center, Durham, North Carolina
EPI-Q Inc., Oak Brook, Illinois
Manuscript received December 18, 2004;
accepted June 28, 2005.
* Reprint requests and correspondence: Dr. Albert L. Waldo, University Hospitals of Cleveland, Division of Cardiology, 11100 Euclid Avenue, Cleveland, Ohio 44106-5038 (Email: albert.waldo{at}case.edu).
OBJECTIVES: The purpose of this study was to determine both treatment gaps and predictors of warfarin use in atrial fibrillation (AF) patients enrolled in a national multicenter study.
BACKGROUND: The National Anticoagulation Benchmark Outcomes Report (NABOR) is a performance improvement program designed to benchmark anticoagulation prophylaxis, treatment, and outcomes among participating hospitals.
METHODS: A retrospective cohort study of inpatients was performed at 21 teaching, 13 community, and 4 Veterans Administration hospitals in the U.S. Patients with an ICD-9-CM code for AF (427.31) were randomly selected.
RESULTS: Among the 945 patients studied, the mean age was 71.5 (± 13.5) years; 43% were >75 years of age, 54.5% were men, and 67% had a history of hypertension. Most (86%) had factors that stratified them as at high risk of stroke, and only 55% of those received warfarin. Neither warfarin nor aspirin were prescribed in 21% of high-risk patients, including 18% of those with a previous stroke, transient ischemic attack, or systemic embolic event. Age >80 years (p = 0.008) and perceived bleeding risk (p = 0.022) were negative predictors of warfarin use. Persistent/permanent AF (p < 0.001) and history of stroke, transient ischemic attack, or systemic embolus (p = 0.014) were positive predictors of warfarin use, whereas high-risk stratification was not.
CONCLUSIONS: This study confirms the under-use of warfarin, but also adds to published reports in several regards. It showed that risk stratification, the guidepost for treatment in international guidelines, had little effect on warfarin use, and that age >80 years and AF classification (permanent/persistent) are factors that influence warfarin use.
|
Abbreviations and Acronyms
| | AF = atrial fibrillation | | AFASAK = Atrial Fibrillation Aspirin and Anticoagulation study | | BAATAF = Boston Area Anticoagulation Trial for Atrial Fibrillation | | CAFA = Canadian Atrial Fibrillation study | | EAFT = European Atrial Fibrillation Trial | | INR = international normalized ratio | | NABOR = National Anticoagulation Benchmark and Outcomes Report | | SPAF = Stroke Prevention in Atrial Fibrillation study | | SPINAF = Stroke Prevention in Nonrheumatic Atrial Fibrillation study | | TIA = transient ischemic attack | | VA = Veterans Administration |
|
This article has been cited by other articles:
|
|
|
|
 
D. R. Holmes Jr and R. S. Schwartz
Left Atrial Appendage Occlusion Eliminates the Need for Warfarin
Circulation,
November 10, 2009;
120(19):
1919 - 1926.
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. J. Connolly, H. J.G.M. Crijns, C. Torp-Pedersen, M. van Eickels, C. Gaudin, R. L. Page, S. H. Hohnloser, and for the ATHENA Investigators
Analysis of Stroke in ATHENA: A Placebo-Controlled, Double-Blind, Parallel-Arm Trial to Assess the Efficacy of Dronedarone 400 mg BID for the Prevention of Cardiovascular Hospitalization or Death From Any Cause in Patients With Atrial Fibrillation/Atrial Flutter
Circulation,
September 29, 2009;
120(13):
1174 - 1180.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
H. Sievert and Y. L. Bayard
Percutaneous Closure of the Left Atrial Appendage: A Major Step Forward
J. Am. Coll. Cardiol. Intv.,
July 1, 2009;
2(7):
601 - 602.
[Full Text]
[PDF]
|
|
|
|
|
|
|
The ACTIVE Investigators
Effect of Clopidogrel Added to Aspirin in Patients with Atrial Fibrillation
N. Engl. J. Med.,
May 14, 2009;
360(20):
2066 - 2078.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Nabauer, A. Gerth, T. Limbourg, S. Schneider, M. Oeff, P. Kirchhof, A. Goette, T. Lewalter, U. Ravens, T. Meinertz, et al.
The Registry of the German Competence NETwork on Atrial Fibrillation: patient characteristics and initial management
Europace,
April 1, 2009;
11(4):
423 - 434.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. Nieuwlaat and S. J Connolly
Stroke prevention in atrial fibrillation: better use of anticoagulation and new agents will lead to improved outcomes
Heart,
January 15, 2009;
95(2):
95 - 97.
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. J. Gladstone, E. Bui, J. Fang, A. Laupacis, M. P. Lindsay, J. V. Tu, F. L. Silver, and M. K. Kapral
Potentially Preventable Strokes in High-Risk Patients With Atrial Fibrillation Who Are Not Adequately Anticoagulated
Stroke,
January 1, 2009;
40(1):
235 - 240.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
Y. L Bayard, S. H Ostermayer, and H. Sievert
Alternatives to warfarin in atrial fibrillation: drugs and devices
Heart,
September 1, 2008;
94(9):
1113 - 1116.
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Meiltz, M. Zimmermann, P. Urban, A. Bloch, and on behalf of the Association of Cardiologists of t
Atrial fibrillation management by practice cardiologists: a prospective survey on the adherence to guidelines in the real world
Europace,
June 1, 2008;
10(6):
674 - 680.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. Nieuwlaat, T. Dinh, S. B. Olsson, A. J. Camm, A. Capucci, R. G. Tieleman, G. Y.H. Lip, H. J.G.M. Crijns, and on behalf of the Euro Heart Survey Investigators
Should we abandon the common practice of withholding oral anticoagulation in paroxysmal atrial fibrillation?
Eur. Heart J.,
April 1, 2008;
29(7):
915 - 922.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. J. Connolly, J. Eikelboom, M. O'Donnell, J. Pogue, and S. Yusuf
Response to Letter Regarding Article, "Challenges of Establishing New Antithrombotic Therapies in Atrial Fibrillation"
Circulation,
February 5, 2008;
117(5):
e150 - e150.
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. J. Connolly, J. Eikelboom, M. O'Donnell, J. Pogue, and S. Yusuf
Challenges of Establishing New Antithrombotic Therapies in Atrial Fibrillation
Circulation,
July 24, 2007;
116(4):
449 - 455.
[Full Text]
[PDF]
|
|
|
|
|
|
|
E. M. Hylek, C. Evans-Molina, C. Shea, L. E. Henault, and S. Regan
Major Hemorrhage and Tolerability of Warfarin in the First Year of Therapy Among Elderly Patients With Atrial Fibrillation
Circulation,
May 29, 2007;
115(21):
2689 - 2696.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
E. Sconce, P. Avery, H. Wynne, and F. Kamali
Vitamin K supplementation can improve stability of anticoagulation for patients with unexplained variability in response to warfarin
Blood,
March 15, 2007;
109(6):
2419 - 2423.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L Kalra, G Y H Lip, and on behalf of the Guideline Development Group for t
Antithrombotic treatment in atrial fibrillation
Heart,
January 1, 2007;
93(1):
39 - 44.
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. Nieuwlaat, A. Capucci, G. Y.H. Lip, S. B. Olsson, M. H. Prins, F. H. Nieman, J. Lopez-Sendon, P. E. Vardas, E. Aliot, M. Santini, et al.
Antithrombotic treatment in real-life atrial fibrillation patients: a report from the Euro Heart Survey on Atrial Fibrillation
Eur. Heart J.,
December 2, 2006;
27(24):
3018 - 3026.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. Friberg, N. Hammar, M. Ringh, H. Pettersson, and M. Rosenqvist
Stroke prophylaxis in atrial fibrillation: who gets it and who does not?: Report from the Stockholm Cohort-study on Atrial Fibrillation (SCAF-study)
Eur. Heart J.,
August 2, 2006;
27(16):
1954 - 1964.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
E. M. Hylek, J. D'Antonio, C. Evans-Molina, C. Shea, L. E. Henault, and S. Regan
Translating the Results of Randomized Trials into Clinical Practice: The Challenge of Warfarin Candidacy Among Hospitalized Elderly Patients With Atrial Fibrillation
Stroke,
April 1, 2006;
37(4):
1075 - 1080.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
