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Warfarin for stroke prevention still underused in atrial fibrillation: patterns of omission
N Cohen1, D Almoznino-Sarafian, I Alon
1Department of Internal Medicine F, Assaf Harofeh Medical Center, Affiliated to Sackler Faculty of Medicine, Tel Aviv University, Zerifin, Israel.
Insights
Warfarin use for stroke prevention in atrial fibrillation is suboptimal, particularly in elderly patients or those with language barriers. Factors like age, language, and doctor awareness significantly influence treatment decisions, indicating a gap in optimal anticoagulation therapy.
Area of Science:
- Cardiology
- Internal Medicine
- Pharmacology
Background:
- Warfarin is crucial for preventing stroke in chronic atrial fibrillation.
- Current warfarin treatment rates often fall short of clinical needs.
- Understanding factors influencing warfarin prescription is essential for improving patient outcomes.
Purpose of the Study:
- To identify demographic, clinical, and echocardiographic factors affecting warfarin treatment decisions in atrial fibrillation patients.
- To explore doctor- and patient-related influences on anticoagulation therapy.
Main Methods:
- Retrospective analysis of 1027 patients discharged with chronic or persistent atrial fibrillation between 1990 and 1998.
- Categorization into groups based on cardiac prosthetic valves, bleeding risk, disability, and a main study group for detailed analysis.
- Statistical analysis to determine independent variables influencing warfarin use.
Main Results:
- Warfarin use varied significantly across patient groups (93.7% in prosthetic valve patients to 17.03% in disabled patients).
- In the main study group, warfarin use increased over time (29.7% to 77.1%).
- Factors negatively associated with warfarin use included advanced age (>80), poor Hebrew command, and specific hospital departments. Positive associations included prior stroke history and availability of echocardiographic data.
Conclusions:
- Reluctance to prescribe warfarin is linked to patient age, language barriers, physician awareness, and patient disability.
- Despite established benefits, warfarin utilization for stroke prevention in atrial fibrillation remains below ideal levels.
Background And Purpose:
The value of warfarin in preventing stroke in patients with chronic atrial fibrillation is well established. However, the prevalence of such treatment generally lags behind actual requirements. The aim of this study was to evaluate doctor- and/or patient-related demographic, clinical, and echocardiographic factors that influence decision for warfarin treatment.
Methods:
Between 1990 and 1998, 1027 patients were discharged with chronic or persistent atrial fibrillation. This population was composed of (1) patients with cardiac prosthetic valves (n=48), (2) those with increased bleeding risks (n=152), (3) physically or mentally handicapped patients (n=317), and (4) the remaining 510 patients, the main study group who were subjected to thorough statistical analysis for determining factors influencing warfarin use.
Results:
The respective rates of warfarin use on discharge in the 4 groups were 93.7%, 30.9%, 17.03%, and 59.4% (P=0.001); of the latter, an additional 28.7% were discharged on aspirin. In the main study group, warfarin treatment rates increased with each consecutive triennial period (29.7%, 53.6%, and 77.1%, respectively; P=0.001). Age >80 years, poor command of Hebrew, and being hospitalized in a given medical department emerged as independent variables negatively influencing warfarin use: P=0.0001, OR 0.30 (95% CI 0.17 to 0.55); P=0.02, OR 0.59 (95% CI 0.36 to 0.94); and P=0.0002, OR 0.26 (95% CI 0.12 to 0.52), respectively. In contrast, past history of stroke and availability of echocardiographic information, regardless of the findings, each increased warfarin use (P=0.03, OR 1.95 [95% CI 1.04 to 3.68], and P=0.0001, OR 3.52 [95% CI 2.16 to 5.72], respectively).
Conclusions:
Old age, language difficulties, insufficient doctor alertness to warfarin benefit, and patient disability produced reluctance to treat. Warfarin use still lags behind requirements.