Oral Anticoagulation in HF Patients With Atrial Fibrillation
Oral Anticoagulation in HF Patients With Atrial Fibrillation
Background We sought to characterize patient factors and regional variations associated with vitamin K antagonist (VKA) use in patients with heart failure (HF) and atrial fibrillation (AF) in areas outside the United States and Europe.
Methods The ADHERE-International registry enrolled patients with decompensated HF from 10 Asia Pacific and Latin American countries from December 2005 to January 2009. Rates of VKA use in patients with HF and either new-onset AF or a history of AF were determined and compared according to CHADS2 scores. Multivariable logistic regression and hierarchical modeling with random effects for hospitals were used to determine clinical and regional factors associated with VKA use at discharge.
Results Among 9,706 admissions, there were 2,358 (24.3%) with prior AF and 674 (6.9%) with new-onset AF. The median age was 71 years (25th-75th percentiles 59–79) for prior AF and 69 (57–80) for new-onset AF patients. The overall rate of VKA use at discharge was 39.5%. Vitamin K antagonist use at discharge was 36.2% in patients with CHADS2 scores ≥2 versus 50.2% in patients with CHADS2 score equal to 1 (P < .0001). Vitamin K antagonist use was 36.4% in patients with hypertension, 28.1% in patients >75 years old, 34.8% in diabetics, and 44.4% in those with prior stroke/transient ischemic attack. After adjusting for patient characteristics, the highest and lowest rates of anticoagulation were in Australia (65.2%) and Taiwan (25.1%).
Conclusion International use of guidelines-recommended anticoagulation in HF patients with AF varies significantly across countries and represents an important opportunity for improving quality of care.
Atrial fibrillation (AF) is the most common cardiac rhythm disturbance, affecting 2.3 million Americans and 4.5 million Europeans. The development of AF in patients with heart failure (HF) is common with an incidence ranging from 2% to 5% per year and a prevalence as high as 50% in patients with New York Heart Association functional class IV symptoms. These patients commonly have diminished quality of life and functional limitations. Patients with AF and HF have an increased long-term risk of stroke leading to increased morbidity, mortality, and health care costs. The European Society of Cardiology (ESC) guidelines for the management of AF recommend that all HF patients with a history of paroxysmal or persistent AF and a CHADS2 score ≥2 be anticoagulated with a vitamin K antagonist (VKA). The 2005 American College of Cardiology/American Heart Association Clinical Performance Measures for Adults with Chronic HF included a performance measure for anticoagulant use at discharge in patients with chronic/recurrent AF and no contraindications. Vitamin K antagonist therapy in patients with AF and HF is also considered a measure of quality of care.
Despite these recommendations, the use of anticoagulation in HF patients with AF varies in clinical practice. In the United States, only two thirds of patients with AF who were discharged from an HF hospitalization were discharged on anticoagulation, and paradoxically, the likelihood of anticoagulation was inversely related to the risk of stroke as assessed by CHADS2 score. In Europe, one third of patients with HF and AF were not anticoagulated with a VKA despite the lack of contraindications.
Although the rates of anticoagulation and patient characteristics for AF among patients discharged from a HF hospitalization have been well characterized in the United States and Europe, much less is known about other areas of the world. The use of VKA in AF patients from 44 countries (in Europe, North and South America, and Asia) with atherothrombotic disease has been reported to be 53%. Recent studies revealed the rate of VKA use in AF patients in Japan to be as high as 87%, whereas the rate in Malaysia was only 16%. These regional differences warrant better characterization and attention.
As awareness of global cardiovascular health and the emergence of new agents for thromboembolic prophylaxis increase, it is important to understand how anticoagulation is used in all areas of the world. We sought to determine the clinical characteristics and regional variations in the use of VKA in patients hospitalized with HF and AF in the ADHERE-International registry.
Abstract and Introduction
Abstract
Background We sought to characterize patient factors and regional variations associated with vitamin K antagonist (VKA) use in patients with heart failure (HF) and atrial fibrillation (AF) in areas outside the United States and Europe.
Methods The ADHERE-International registry enrolled patients with decompensated HF from 10 Asia Pacific and Latin American countries from December 2005 to January 2009. Rates of VKA use in patients with HF and either new-onset AF or a history of AF were determined and compared according to CHADS2 scores. Multivariable logistic regression and hierarchical modeling with random effects for hospitals were used to determine clinical and regional factors associated with VKA use at discharge.
Results Among 9,706 admissions, there were 2,358 (24.3%) with prior AF and 674 (6.9%) with new-onset AF. The median age was 71 years (25th-75th percentiles 59–79) for prior AF and 69 (57–80) for new-onset AF patients. The overall rate of VKA use at discharge was 39.5%. Vitamin K antagonist use at discharge was 36.2% in patients with CHADS2 scores ≥2 versus 50.2% in patients with CHADS2 score equal to 1 (P < .0001). Vitamin K antagonist use was 36.4% in patients with hypertension, 28.1% in patients >75 years old, 34.8% in diabetics, and 44.4% in those with prior stroke/transient ischemic attack. After adjusting for patient characteristics, the highest and lowest rates of anticoagulation were in Australia (65.2%) and Taiwan (25.1%).
Conclusion International use of guidelines-recommended anticoagulation in HF patients with AF varies significantly across countries and represents an important opportunity for improving quality of care.
Introduction
Atrial fibrillation (AF) is the most common cardiac rhythm disturbance, affecting 2.3 million Americans and 4.5 million Europeans. The development of AF in patients with heart failure (HF) is common with an incidence ranging from 2% to 5% per year and a prevalence as high as 50% in patients with New York Heart Association functional class IV symptoms. These patients commonly have diminished quality of life and functional limitations. Patients with AF and HF have an increased long-term risk of stroke leading to increased morbidity, mortality, and health care costs. The European Society of Cardiology (ESC) guidelines for the management of AF recommend that all HF patients with a history of paroxysmal or persistent AF and a CHADS2 score ≥2 be anticoagulated with a vitamin K antagonist (VKA). The 2005 American College of Cardiology/American Heart Association Clinical Performance Measures for Adults with Chronic HF included a performance measure for anticoagulant use at discharge in patients with chronic/recurrent AF and no contraindications. Vitamin K antagonist therapy in patients with AF and HF is also considered a measure of quality of care.
Despite these recommendations, the use of anticoagulation in HF patients with AF varies in clinical practice. In the United States, only two thirds of patients with AF who were discharged from an HF hospitalization were discharged on anticoagulation, and paradoxically, the likelihood of anticoagulation was inversely related to the risk of stroke as assessed by CHADS2 score. In Europe, one third of patients with HF and AF were not anticoagulated with a VKA despite the lack of contraindications.
Although the rates of anticoagulation and patient characteristics for AF among patients discharged from a HF hospitalization have been well characterized in the United States and Europe, much less is known about other areas of the world. The use of VKA in AF patients from 44 countries (in Europe, North and South America, and Asia) with atherothrombotic disease has been reported to be 53%. Recent studies revealed the rate of VKA use in AF patients in Japan to be as high as 87%, whereas the rate in Malaysia was only 16%. These regional differences warrant better characterization and attention.
As awareness of global cardiovascular health and the emergence of new agents for thromboembolic prophylaxis increase, it is important to understand how anticoagulation is used in all areas of the world. We sought to determine the clinical characteristics and regional variations in the use of VKA in patients hospitalized with HF and AF in the ADHERE-International registry.
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