on May 21, 2007
Published online before print May 21, 2007, doi: 10.1161/CIRCULATIONAHA.106.653048
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Submitted on July 21, 2006
From the Department of Medicine (E.M.H., L.E.H.), Section of General Internal Medicine-Research Unit, Boston University School of Medicine, Boston Medical Center, and Department of Medicine (C.S., S.R.), General Medicine Division, Massachusetts General Hospital, Boston, Mass; and Department of Medicine (C.E.-M.), University of Virginia, Charlottesville, Va. * To whom correspondence should be addressed. E-mail: ehylek{at}bu.edu.
Background--Warfarin is effective in the prevention of stroke in atrial fibrillation but is under used in clinical care. Concerns exist that published rates of hemorrhage may not reflect real-world practice. Few patients Methods and Results--Consecutive patients who started warfarin were identified from January 2001 to June 2003 and followed for 1 year. Patients had to be Conclusions--Rates of hemorrhage derived from younger noninception cohorts underestimate the bleeding that occurs in practice. This finding coupled with the short-term tolerability of warfarin likely contributes to its underutilization. Stroke prevention among elderly patients with atrial fibrillation remains a challenging and pressing health concern.
Accepted on March 13, 2007
Major Hemorrhage and Tolerability of Warfarin in the First Year of Therapy Among Elderly Patients With Atrial Fibrillation
Elaine M. Hylek MD, MPH*,
80 years of age were enrolled in trials, and studies of prevalent use largely reflect a warfarin-tolerant subset. We sought to define the tolerability of warfarin among an elderly inception cohort with atrial fibrillation.65 years of age, have established care at the study institution, and have their warfarin managed on-site. Outcomes included major hemorrhage, time to termination of warfarin, and reason for discontinuation. Of 472 patients, 32% were 80 years of age, and 91% had 1 stroke risk factor. The cumulative incidence of major hemorrhage for patients 80 years of age was 13.1 per 100 person-years and 4.7 for those <80 years of age (P=0.009). The first 90 days of warfarin, age 80 years, and international normalized ratio (INR) 4.0 were associated with increased risk despite trial-level anticoagulation control. Within the first year, 26% of patients 80 years of age stopped taking warfarin. Perceived safety issues accounted for 81% of them. Rates of major hemorrhage and warfarin termination were highest among patients with CHADS2 scores (an acronym for congestive heart failure, hypertension, age 75, diabetes mellitus, and prior stroke or transient ischemic attack) of 3.
Key words: anticoagulants • atrial fibrillation • hemorrhage • stroke
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