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Warfarin persistence among atrial fibrillation patients – why is treatment ended?
Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin. (Sundsvall Research Unit, Umeå University)
Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin. (Sundsvall Research Unit, Umeå University)
Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin.
2016 (Engelska)Ingår i: Cardiovascular Therapeutics, ISSN 1755-5914, Vol. 34, nr 6, s. 468-474Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Background and Aim

Warfarin treatment discontinuation is significant among patients with atrial fibrillation (AF). Studies mainly focused on whether the proportion of warfarin persistence and discontinuationare clinically appropriate are absent. This study evaluates warfarin persistence with focus on predictors for, and reasons to, warfarin discontinuation in AF patients.

Methods

From the national quality register AuriculA, all AF patients in Sundsvall, Sweden, on warfarin treatment on January first, 2010 were included. These 478 patients were followed until discontinuation or study-stop December 31, 2013. By going through each patient’s medical record risk factors for thromboembolism, bleeding and causes of discontinuation were obtained.

Results

Proportion of warfarin persistence was 0.91 (95% confidence interval (CI) 0.89 to 0.93) after one year and 0.73 (95% CI 0.69 to 0.77) after four years. Previous intracranial bleeding, excessive alcohol use, anemia and pulmonary or peripheral emboli were each associated with over two times higher risk of discontinuation (hazard ratio (HR) 5.66, CI 2.23-14.36, HR 2.54, CI 1.48-4.37, HR 2.40, CI 1.38-4.17, and HR 2.13, CI 1.02-4.46). Among patients discontinuing, 50.5% were due to questionable causes, such as sinus rhythm (33.9%), patients demand (10.1%) and falls (8.2%). The majority (43.1%) of treatment discontinuers were changed to aspirin, while 40.4% of them were left without medical stroke prophylaxis.

Conclusions

Although persistence to warfarin among AF patients proves higher than previously reported, there is room for improvement since half of the discontinuers have questionable reasons for treatment stop and the majority of them receive no other efficient stroke prophylaxis.

Ort, förlag, år, upplaga, sidor
2016. Vol. 34, nr 6, s. 468-474
Nyckelord [en]
Atrial fibrillation, Discontinuation, Persistence, Stroke prophylaxis, Treatment, Warfarin
Nationell ämneskategori
Hematologi Kardiologi
Forskningsämne
medicin, hjärt- och kärlforskning
Identifikatorer
URN: urn:nbn:se:umu:diva-125990DOI: 10.1111/1755-5922.12224ISI: 000388370600010PubMedID: 27565120OAI: oai:DiVA.org:umu-125990DiVA, id: diva2:974253
Tillgänglig från: 2016-09-26 Skapad: 2016-09-26 Senast uppdaterad: 2018-06-07Bibliografiskt granskad
Ingår i avhandling
1. Warfarin treatment quality in stroke prevention
Öppna denna publikation i ny flik eller fönster >>Warfarin treatment quality in stroke prevention
2016 (Engelska)Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
Abstract [en]

Background

Ischemic stroke is a serious condition often associated to presence of atrial fibrillation (AF). Use of anticoagulants for AF patients greatly reduces the risk of stroke. Warfarin is the most commonly used anticoagulant in Sweden. The aim of this thesis was to study the impact of warfarin treatment quality in Swedish stroke prevention.

Methods

Study I, II and IV were relatively large multicentre, retrospective, cohort studies based on Swedish registries, especially AuriculA, a quality register for AF and anticoagulation. Background data as well as bleeding and thromboembolic complications were retrieved from the National Patient Register. The Cause of Death Register was used in study II and IV. The Swedish Prescribed Drug Register was used in study IV, for data on concomitant acetylsalicylic acid (ASA) use. Study period was January 1, 2006, to December 31, 2011. Study III enrolled all warfarin treated AF patients in Sundsvall, registered in AuriculA on January 1, 2010. This smaller cohort was followed until discontinuation or study-stop December 31, 2013. All used data were collected from each patient’s medical record.

Results

The annual risk of major bleedings and thromboembolic events for warfarin treated patients, including all different indications for warfarin, was relatively low (2.24% and 2.66%), with incidence of intracranial bleeding of 0.37% per treatment year. The overall mean time in therapeutic range (TTR) was 76.5%. Patients started on warfarin due to AF had a mean TTR of 68.6%, with an annual risk of major bleeding and thromboembolic events of 2.23% and 2.95%, and with 0.44% annual risk of intracranial bleeding. No significant differences in overall complications were found when comparing treatment monitored in anticoagulation clinics (ACC) with treatment monitored in primary health care centers (PHCC). There were significantly increased risk of both overall major bleedings and thromboembolic events for those warfarin treated AF patients receiving additional ASA treatment, having individual TTR (iTTR) below 70%, or having high international normalized ratio (INR) variability. AF patients with low INR variability had generally lower complication rates, compared with patients with high INR variability. There were however no alteration on cumulative incidence of complications due to INR variability, for AF patients with iTTR ≥70%. The overall proportion of persistence to warfarin treatment for stroke patients with AF was found to be 0.69 after 2 years treatment and 0.47 after 5 years. Stroke patients with diagnosed dementia at baseline were more than two-times likely of discontinuing warfarin than others. Excessive alcohol use, chronic obstructive pulmonary disease, cancer and chronic heart failure were baseline diagnoses each associated with over 20% increased risk of treatment discontinuation. Lower persistence to treatment was linked to increasing start-age and CHA2DS2-VASc scores. As documented reasons for warfarin treatment discontinuation in AF patients, we found regained sinus rhythm as the most common addressed cause (31.2%), followed by problematic monitoring and bleedings. We estimated that only half (49.5%) of the treatment discontinuations were clinically well motivated.

Conclusions

Quality of Swedish warfarin treatment in initiated stroke prevention is high, with generally low rates of complications and high TTRs, no matter treatment in ACC or PHCC, including high long time persistence to warfarin in secondary stroke prevention. For better outcome in future warfarin stroke prophylactic treatment clinicians should aim for iTTRs above 70%, avoid additional ASA therapy, support fragile patients like those with excessive alcohol use and dementia, and base decisions on treatment discontinuations on solid medical arguments.

Ort, förlag, år, upplaga, sidor
Umeå: Umeå University, 2016. s. 50
Serie
Umeå University medical dissertations, ISSN 0346-6612 ; 1827
Nyckelord
Anticoagulation, atrial fibrillation, complications, international normalized ratio (INR) variability, persistence, stroke, time in therapeutic range (TTR), treatment quality, warfarin
Nationell ämneskategori
Kardiologi Hematologi
Forskningsämne
medicin, hjärt- och kärlforskning
Identifikatorer
urn:nbn:se:umu:diva-125998 (URN)978-91-7601-513-1 (ISBN)
Disputation
2016-10-21, Aulan, Utbildningslokalerna 1 trp, Sundsvalls sjukhus, Sundsvall, 13:00 (Svenska)
Opponent
Handledare
Tillgänglig från: 2016-09-30 Skapad: 2016-09-26 Senast uppdaterad: 2018-06-07Bibliografiskt granskad

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