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Oral anticoagulation in patients with atrial fibrillation: adherence with guidelines in an elderly cohort
R H White1, M A McBurnie, T Manolio
1University of California, Davis, Sacramento, USA.
Insights
Most elderly patients with atrial fibrillation (AF) are not treated with warfarin, despite guidelines recommending it for stroke prevention. Further research is needed to understand this gap in care for older adults with AF.
Area of Science:
- Gerontology
- Cardiology
- Pharmacology
Background:
- Atrial fibrillation (AF) is a common arrhythmia in elderly individuals.
- Stroke is a major complication of AF, and anticoagulation is recommended for prevention.
- Warfarin is a widely used anticoagulant for stroke prevention in AF patients.
Purpose of the Study:
- To assess the adherence to practice guidelines for warfarin use in a population-based cohort of elderly individuals (≥70 years) with atrial fibrillation.
- To identify factors associated with warfarin use in this high-risk population.
Main Methods:
- Cross-sectional analysis of participants from the Cardiovascular Health Study (1993-1995).
- Inclusion criteria: participants aged ≥70 years with atrial fibrillation and no contraindications to warfarin.
- Outcome measure: self-reported warfarin use in 1995.
Main Results:
- In 1995, 172 participants had AF without contraindications to warfarin; only 37% were using warfarin.
- Of those not on warfarin, 84% had clinical risk factors for stroke.
- Warfarin use was independently associated with younger age, higher cognitive function, and male sex (in patients without prior stroke).
Conclusions:
- Adherence to warfarin guidelines for stroke prevention in elderly patients with atrial fibrillation is low.
- A significant proportion of high-risk AF patients are not receiving recommended anticoagulation therapy.
- Further investigation is required to elucidate barriers to warfarin use in this demographic.
Purpose:
To determine adherence with practice guidelines in a population-based cohort of elderly persons aged 70 years or older with atrial fibrillation.
Subjects And Methods:
This was a cross-sectional analysis of a subgroup of participants in the Cardiovascular Health Study, a prospective observational study involving four communities in the United States. Subjects were participants with atrial fibrillation on electrocardiogram at one or more yearly examinations from 1993 to 1995. The outcome measure was self-reported use of warfarin in 1995.
Results:
In 1995, 172 (4.1%) participants had atrial fibrillation together with information regarding warfarin use and no preexisting indication for its use. Warfarin was used by 63 (37%) of these participants. Of the 109 participants not reporting warfarin use, 92 (84%) had at least one of the clinical risk factors (aside from age) associated with stroke in patients with atrial fibrillation. Among participants not taking warfarin, 47% were taking aspirin. Several characteristics were independently associated with warfarin use, including age [odds ratio (OR) = 0.6 per 5-year increment, 95% CI 0.5-0.9], a modified mini-mental examination score <85 points [OR = 0.3, 95% confidence interval (CI) 0.1-0.9], and among patients without prior stroke, female sex (OR = 0.5, 95% CI 0.2-1.0).
Conclusions:
Despite widely publicized practice guidelines to treat patients who have atrial fibrillation with warfarin, most participants who had atrial fibrillation were at high risk for stroke but were not treated with warfarin. More studies are needed to determine why elderly patients with atrial fibrillation are not being treated with warfarin.