Author + information
- Received January 19, 2009
- Revision received March 24, 2009
- Accepted April 3, 2009
- Published online September 29, 2009.
- Jonathan P. Piccini, MD*,
- Adrian F. Hernandez, MD, MHS*,* (, )
- Xin Zhao, PhD*,
- Manesh R. Patel, MD*,
- William R. Lewis, MD†,
- Eric D. Peterson, MD, MPH*,
- Gregg C. Fonarow, MD‡,
- Get With The Guidelines Steering Committee and Hospitals
- ↵*Reprint requests and correspondence:
Dr. Adrian F. Hernandez, Duke Clinical Research Institute, P.O. Box 17969, Durham, North Carolina 27715
Objectives This study sought to examine quality of care and warfarin use at discharge in patients with atrial fibrillation (AF) and heart failure (HF).
Background Atrial fibrillation is common in HF, and national guidelines recommend discharge on warfarin for stroke prophylaxis. However, the frequency and factors associated with the guideline adherence are poorly described.
Methods We analyzed 72,534 HF admissions from January 2005 through March 2008 at 255 hospitals participating in the American Heart Association's Get With The Guidelines HF program. Multivariable logistic regression was used to identify independent factors associated with warfarin use at discharge.
Results In this HF population, 20.5% (n = 14,901) had AF on admission, whereas another 13.7% (n = 9,918) had a prior history of AF but were in a regular rhythm at admission. Contraindications to warfarin therapy were documented in 9.2%. Among eligible HF patients without contraindications, the median prevalence of warfarin therapy at discharge was 64.9% (interquartile range 55.5 to 73.4) and did not improve during the 3.5 years of study. After adjustment, major factors associated with no warfarin use at discharge included increasing age, nonwhite race, anemia, and treatment in the south. Warfarin use also varied inversely with CHADS2(congestive heart failure, hypertension, age >75, diabetes, and prior stroke or transient ischemic attack) risk (70.9% to 59.5% for CHADS2score 1 to 6, p < 0.0001).
Conclusions Guideline-recommended warfarin use in patients with AF and HF is less than optimal, has not improved over time, and varies significantly according to age, race, risk profile, region, and hospital site.
The Get With The Guidelines Heart Failure program is supported by an unrestricted educational grant from GlaxoSmithKline. Dr. Piccini is supported by an American College of Cardiology Foundation/Merck Award. Dr. Hernandez is supported by American Heart Association Pharmaceutical Roundtable grant 0675060N; has received research grants from Johnson & Johnson (Scios), Merck, and GlaxoSmithKline; and has received honoraria from Novartis and AstraZeneca. Drs. Hernandez and Peterson are supported by grant 1U18HS016964 from the Agency for Health care Research and Quality. Dr. Patel is on the advisory board of Genzyme. Dr. Lewis has served as a consultant/speaker for Medtronic (modest). Dr. Peterson has received grant/research support from Bristol-Myers Squibb/Sanofi and Schering-Plough. Dr. Fonarow is supported by the Ahmanson Foundation (Los Angeles, California); has received research grants from GlaxoSmithKline/Medtronic; has received honoraria from Bristol-Myers Squibb/Sanofi, GlaxoSmithKline, Medtronic, and Schering-Plough; served as a consultant for GlaxoSmithKline, Medtronic, Sanofi-Aventis, Schering-Plough, and Scios; and serves as chair of the American Heart Association's Get With The Guidelines Steering Committee.
- Received January 19, 2009.
- Revision received March 24, 2009.
- Accepted April 3, 2009.
- American College of Cardiology Foundation