Arrhythmias and conduction disturbance
Differential Use of Warfarin for Secondary Stroke Prevention in Patients With Various Types of Atrial Fibrillation

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Anticoagulation therapy significantly reduces the incidence of thromboembolic events in patients with atrial fibrillation (AF), and warfarin therapy at discharge is a class I–indicated drug in patients with ischemic stroke with persistent or paroxysmal AF without contraindications. The aim was to determine whether participation in the Get With The Guidelines-Stroke (GWTG-S) quality improvement program would be associated with improved adherence to anticoagulation guidelines for patients with all types of AF. Adherence to warfarin treatment at hospital discharge was assessed in eligible patients with AF who presented with stroke or transient ischemic attack, based on type of AF. Of patients with stroke, 10.5% presented with some form of AF. When AF was documented using electrocardiography or telemetry (ECG) during the present admission, eligible patients were more likely to receive warfarin compared with patients for whom AF was reported using medical history only (78.8% vs 49.4%; p <0.0001). Improvement after GWTG-S participation in warfarin use was observed in patients with ECG-documented AF (73.8% at baseline vs 88.5% after the intervention; p <0.0001), but not patients using history only. Women and elderly patients were less likely to receive warfarin, and these gaps in treatment did not narrow during the quality improvement program for patients with ECG-documented AF and those with history only. In conclusion, anticoagulation for stroke prevention was underused in general for patients with AF, even in such high-risk groups as patients with stroke. GWTG-S was associated with improved adherence for patients with ECG-documented AF, but patients with a history of AF alone were largely untreated.

Section snippets

Methods

The GWTG-S database was queried for demographic, clinical, and treatment data for consecutive patients presenting with ischemic stroke or TIA (International Classification of Diseases, Ninth Revision codes 433 to 436) and AF. Hospitals were recruited to participate during the course of the study. Mean follow-up in participating hospitals was 5.72 quarters. There were 562 participating hospitals from October 1, 2001, to when the data were analyzed as of December 31, 2005. GWTG-S uses preprinted

Results

A total of 147,128 patients with stroke were entered into the GWTG-S database from October 1, 2001, to December 31, 2005, at 562 hospitals with an average of 355 beds/institution. Characteristics of these hospitals are listed in Table 1. A total of 1,970 patients had documented contraindications to anticoagulation therapy in the database and were excluded. Contraindications were more frequently documented in group 1 compared with group 2 (1,940 of 9,575 vs 100 of 7,926 patients; p <0.0001).

Discussion

This was the first study to show that a comprehensive quality improvement program such as GWTG-S was associated with significantly improved adherence to anticoagulation guidelines in patients with stroke and electrocardiographic and telemetry evidence of AF. The observed success of this program may be caused by its comprehensive nature using an Internet-based concurrent Patient Management Tool, preprinted orders, educational conferences, and quality improvement review processes. This study also

Acknowledgment

The contents of this report are solely the responsibility of the authors and do not necessarily represent the official view of the National Center for Research Resources or National Institutes of Health. Dr. Lewis had full access to all data in the study and takes responsibility for the integrity of the data and accuracy of the data analysis.

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The data analysis of this study was performed by the Duke Clinical Research Institute, Durham, North Carolina, and funded by the American Heart Association, Dallas Texas. Dr. Super was supported by Grant No. M01 RR000080 from the National Center for Research Resources, National Institutes of Health, Bethesda, Maryland. Dr. Lewis has received speaker honoraria from Reliant Pharmaceuticals. Dr. Fonarow has received research grants from GlaxoSmithKline and honoraria from GlaxoSmithKline, Merck, Schering-Plough, and Bristol Myers Squibb and is or has been a consultant for Glaxo-Smith-Kline, Schering-Plough, Merck, and Bristol Myers Squibb. Dr. Cannon has received research grants from Accumetrics, AstraZeneca, Bristol-Myers Squibb, Glaxo Smith Kline, Merck, Sanofi-Aventis, and Schering Plough.

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