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Warfarin use following ischemic stroke among Medicare patients with atrial fibrillation
L M Brass1, H M Krumholz, J D Scinto
1Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, Yale University School of Medicine, Conn 06520-8018, USA. lawrence.brass@yale.edu
Insights
Warfarin sodium is underused in elderly patients with atrial fibrillation and ischemic stroke, even in ideal candidates. Increased warfarin use can significantly reduce recurrent stroke risk in this high-risk group.
Area of Science:
- Geriatric Medicine
- Cardiology
- Neurology
Background:
- Elderly patients with atrial fibrillation (AF) and ischemic stroke face a high risk of recurrent stroke.
- Warfarin sodium is a proven, effective anticoagulant for stroke risk reduction in AF patients.
Purpose of the Study:
- To assess the utilization of warfarin in elderly patients hospitalized for ischemic stroke with atrial fibrillation.
- To identify patterns in warfarin prescription at discharge for this patient cohort.
Main Methods:
- A chart review was conducted on Medicare patients aged 65+ hospitalized in 1994 with atrial fibrillation.
- Exclusion criteria included acute myocardial infarction or other indications for anticoagulation.
- Data analysis focused on stroke as a principal diagnosis and discharge medication.
Main Results:
- Only 53% of eligible patients discharged alive after a stroke were prescribed warfarin.
- Among those not prescribed warfarin, a significant portion also did not receive aspirin.
- Ideal candidates (high stroke risk, low bleeding risk) had a 62% warfarin prescription rate at discharge.
Conclusions:
- Warfarin anticoagulation is underutilized in elderly stroke patients with atrial fibrillation, including ideal candidates.
- There is a significant opportunity to improve recurrent stroke prevention by increasing warfarin use in this population.
- Optimizing anticoagulation therapy can substantially reduce stroke recurrence and improve outcomes.
Background:
Elderly patients with ischemic stroke and atrial fibrillation are at especially increased risk for recurrent stroke. Warfarin sodium is highly effective in reducing this risk.
Objective:
To determine the use of warfarin among a population sample of elderly patients with atrial fibrillation hospitalized for ischemic stroke.
Methods:
The Connecticut Peer Review Organization conducted a chart review of Medicare patients, aged 65 years or older, hospitalized in 1994 with a diagnosis of atrial fibrillation. Patients with a principal diagnosis of acute myocardial infarction or another indication for anticoagulation were excluded.
Results:
Among 635 patients (402 women; 585 white; 218 > or =85 years old; 147 with a new diagnosis of atrial fibrillation), 334 had stroke as a principal diagnosis. Among those discharged alive after a stroke, only 147 (53%) of 278 were prescribed warfarin at discharge. Furthermore, among 130 (47%) of 278 patients not prescribed warfarin at discharge, 81 (62%) of 130 were also not prescribed aspirin. Increased potential benefit (additional vascular risk factors) was not associated with a higher rate of warfarin use. Low risk for anticoagulation (lack of risk factors for bleeding) was associated with a slightly higher rate of warfarin use. Among those with an increased risk of stroke and a low risk for bleeding (ideal candidates), 124 (62%) of 278 were discharged on a regimen of warfarin.
Conclusion:
Anticoagulation of elderly stroke patients with atrial fibrillation, even among ideal candidates, is underused. The increased use of warfarin among these patients represents an excellent opportunity for reducing the risk of recurrent stroke in this high-risk population.