Racial/Ethnic Differences in Ischemic Stroke Rates and the Efficacy of Warfarin Among Patients With Atrial Fibrillation

Shen, Albert Yuh-Jer; Yao, Janis F.; Brar, Somjot; Jorgensen, Michael B.; Wang, Xunzhang; Chen, Wansu

doi:10.1161/strokeaha.107.508580

Cited by 74 publications

(51 citation statements)

References 42 publications

(40 reference statements)

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“…A previous study suggested that in Asian populations the administration of warfarin was more effective as compared with white populations in the setting of stroke prevention. 19 Consistent with that finding, our data demonstrated a significantly reduced MACCE rate in relation to triple antithrombotic therapy in Asians. Cox regression analysis indicated non-administration of warfarin and a baseline CHADS2 score ≥2 were independent predictors of overall MACCE.…”

Section: Discussionsupporting

confidence: 91%

Comparison of Different Antithrombotic Regimens for Patients With Atrial Fibrillation Undergoing Drug-Eluting Stent Implantation

Gao

Zhou

Wang

et al. 2010

Circ J

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Background: The optimal antithrombotic strategy for patients with atrial fibrillation (AF) undergoing drug-eluting stent (DES) implantation is unknown. Methods and Results:The 622 consecutive AF patients undergoing DES implantation were prospectively enrolled. Among them, 142 patients (TT group) continued triple antithrombotic therapy comprising aspirin, clopidogrel and warfarin after discharge; 355 patients (DT group) had dual antiplatelet therapy; 125 patients (WS group) were discharged with warfarin and a single antiplatelet agent. Target INR was set as 1.8-2.5 and was regularly monitored after discharge. The TT group had a significant reduction in stroke and major adverse cardiac and cerebral events (MACCE) (8.8% vs 20.1% vs 14.9%, P=0.010) as compared with either the DT or WS group. In the Cox regression analysis, administration with warfarin (hazard ratio (HR) 0.49; 95% confidence interval (CI) 0.31-0.77; P=0.002) and baseline CHADS2 score ≥2 (HR 2.09; 95%CI 1.27-3.45; P=0.004) were independent predictors of MACCE. Importantly, the incidence of major bleeding was comparable among 3 groups (2.9% vs 1.8% vs 2.5%, P=0.725), although the overall bleeding rate was increased in the TT group. Kaplan-Meier analysis indicated that the TT group was associated with the best net clinical outcome. Conclusions:The cardiovascular benefits of triple antithrombotic therapy were confirmed by reducing the MACCE rate, and its major bleeding risk might be acceptable if the INR is closely monitored. (Circ J 2010; 74: 701 - 708)

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Section: Discussionsupporting

confidence: 91%

Comparison of Different Antithrombotic Regimens for Patients With Atrial Fibrillation Undergoing Drug-Eluting Stent Implantation

Gao

Zhou

Wang

et al. 2010

Circ J

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“…14 The overall mean TTR in our study (53.7%) is also similar to the 54.5% reported for 8992 individuals with AF from Kaiser Permanente Southern California 19 but lower than the 62.5% reported from Kaiser Permanente Northern California. 20 Differences in the proportion of patients newly starting warfarin, the proportion of patients managed through anticoagulation clinics, and the health status of the AF populations studied may partly account for the disparity.…”

Section: Discussionsupporting

confidence: 77%

National Assessment of Warfarin Anticoagulation Therapy for Stroke Prevention in Atrial Fibrillation

et al. 2014

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The goal of our study was to provide a comprehensive and unbiased assessment of anticoagulation care in the United States by taking advantage of a unique data resource. Quest Diagnostics provides laboratory testing services to approximately half of the physician practices in the United States, with nearly 150 million patient encounters annually. The national scope of this database, coupled with the uniformity of the INR assay, provides an unprecedented opportunity to assess anticoagulation care in routine practice outside of hospitals (medical centers). We also examined the relationship of TTR to demographic features, physician case load, geographic region, duration of INR monitoring, and economic status.Background-Anticoagulation control with warfarin, as assessed by the international normalized ratio (INR), is challenging.Time in the therapeutic range has been inversely correlated with major hemorrhage, thrombosis, and mortality. Quest Diagnostics offers standardized INR laboratory testing services to approximately half of US physician practices. To inform national stroke prevention strategies, we evaluated anticoagulation control in office-based community practices. Methods and Results-We selected individuals with ≥2 months of INR data, INR results of >1.2, and an ICD-9 diagnosis code of atrial fibrillation. Frequency of INR testing and time in the therapeutic range were analyzed by age, sex, length of testing period, number of referred patients per provider, and median household income (based on home ZIP code). We identified 138 319 individuals referred by 37 939 physicians, yielding a total of 2 683 674 INR results. Patients had a mean age of 74 years; 81% were ≥65 years of age, and 55% were ≥75 years of age. The mean time in the therapeutic range was 53.7% overall and improved with time on treatment, increasing from 47.6% for patients with <6 months of testing to 57.5% for those with ≥6 months of testing (P<0.0001). The number of patients tested per physician practice was positively associated with time in the therapeutic range. Younger age, female sex, and lower income were also independently associated with poorer anticoagulant control. Conclusion-This study demonstrates widespread suboptimal anticoagulation control, suggesting an urgent need to improve oral anticoagulation care for most patient segments in the United States.

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“…Bhandari et al reported that African-American patients spent less time in range compared with White-American patients (32.2% vs 42.0%, p < 0.001) [27]. Another study showed that African-Americans spent more time in the sub-therapeutic range (INR < 2) [28]. …”

Section: Discussionmentioning

confidence: 99%

Age is associated with time in therapeutic range for warfarin therapy in patients with atrial fibrillation

et al. 2016

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BackgroundWarfarin is the most prescribed oral anticoagulant used for preventing stroke in patients with atrial fibrillation. Time in the therapeutic range (TTR) has been accepted as the best method to evaluate the quality of warfarin therapy. The main aim of the present study was to evaluate the impact of variables on the time in the therapeutic range for warfarin therapy in patients with atrial fibrillation from a referral cardiovascular hospital.MethodsThis retrospective study included 443 patients were included (190 patients with age < 65 years and 253 patients with age ≥65 years) from 2011 to 2014 and TTR was computed according to Rosendaal's method.ResultsPatients with age ≥65 years had higher TTR value (67±22%) compared with patients with < 65 years (60±24%) (p = 0.004). In a linear regression model, only age ≥65 years emerged as a significant predictor of greater TTR values. In multivariate logistic regression model, the variable age ≥65 years was associated with higher OR for having a TTR higher than the median value (OR = 2.17, p < 0.001).ConclusionWe suggest that the age influenced TTR through greater drug adherence. Strategies for increasing drug adherence might improve quality of warfarin anticoagulation.

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Racial/Ethnic Differences in Ischemic Stroke Rates and the Efficacy of Warfarin Among Patients With Atrial Fibrillation

Cited by 74 publications

References 42 publications

Comparison of Different Antithrombotic Regimens for Patients With Atrial Fibrillation Undergoing Drug-Eluting Stent Implantation

Comparison of Different Antithrombotic Regimens for Patients With Atrial Fibrillation Undergoing Drug-Eluting Stent Implantation

National Assessment of Warfarin Anticoagulation Therapy for Stroke Prevention in Atrial Fibrillation

Age is associated with time in therapeutic range for warfarin therapy in patients with atrial fibrillation

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