(Stroke. 1997;28:2382-2389.)
© 1997 American Heart Association, Inc.
Articles |
Warfarin Use Among Patients With Atrial Fibrillation
From the Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, Conn (L.M.B., H.M.K.); Neurology Service, VA Connecticut Healthcare System, West Haven (L.M.B.); Yale Stroke Program, Department of Neurology (L.M.B.), Section of Chronic Disease Epidemiology, School of Epidemiology and Public Health (L.M.B., H.M.K.), and Department of Cardiology (H.M.K.), Yale University School of Medicine, New Haven, Conn; Connecticut Peer Review Organization, Middletown (L.M.B., H.M.K., J.M.S., M.R.); and Department of Cardiology (M.R.), University of Connecticut Health Sciences Center, Farmington.
Correspondence to Lawrence M. Brass, MD, Yale Stroke Program, Department of Neurology, LCI-700, Yale University School of Medicine, 15 York St, PO Box 208018, New Haven, CT 06520-8018. E-mail lawrence.brass{at}yale.edu
Background and Purpose Warfarin reduces the rate of stroke among patients with atrial fibrillation. We sought to determine warfarin use within a population sample of elderly patients with atrial fibrillation.
Methods The Connecticut Peer Review Organization conducted a
chart review of Medicare patients aged 
65 years with a history of
atrial fibrillation before a hospitalization during the first 6 months
of 1994.
Results Among 488 patients (308 women; 457 white; 173 aged 85
years), 38% (184/488) had a relative contraindication to
anticoagulation (history of bleeding, dementia, alcohol use, falls,
cancer, or the need for nonsteroidal anti-inflammatory drugs). Among
the remaining patients (with known atrial fibrillation, but without a
contraindication), only 38% (117/304) had been prescribed warfarin. Of
those not prescribed warfarin, 63% (117/187) were also not taking
aspirin. There were 272 patients with at least one additional vascular
risk factor and no contraindication to anticoagulation. Among these
patients at moderate to high risk for stroke, anticoagulation had been
prescribed in 40% (109/272). Overall, among those not prescribed
warfarin, 58% (95/163) were not taking aspirin. Patients admitted with
a stroke were more likely to be significantly underanticoagulated (with
international normalized ratio <1.5) (43.5% versus 20.9% for those
without stroke; P<.005). Anticoagulation was most
effective for those with an international normalized ratio 2.0.
Conclusions Warfarin anticoagulation with atrial fibrillation, even among "ideal" candidates, appears dramatically underutilized. In addition, among those prescribed warfarin, patients are often undertreated. Increased warfarin use among patients with atrial fibrillation represents an excellent opportunity for stroke prevention in the elderly.
Key Words: anticoagulants • atrial fibrillation • stroke prevention • warfarin
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