Warfarin for stroke prevention still underused in atrial fibrillation - Patterns of omission

Background and Purpose--The value of warfarin in preventing stroke in patie nts with chronic atrial fibrillation is well established. However, the prev alence of such treatment generally lags behind actual requirements. The aim of this study was to evaluate doctor- and/or patient-related demographic, clinical, and echocardiographic factors that influence decision for warfari n treatment. Methods-Between 1990 and 1998, 1027 patients were discharged with chronic o r persistent atrial fibrillation. This population was composed of (1) patie nts with cardiac prosthetic valves (n=48), (2) those with increased bleedin g risks (n=152), (3) physically or mentally handicapped patients (n=317), a nd (4) the remaining 510 patients, the main study group who were subjected to thorough statistical analysis for determining factors influencing warfar in use. Results-The respective rates of warfarin use on discharge in the 4 groups w ere 93.7%, 30.9%, 11.03%, and 59.4% (P=0.001); of the latter, an additional 28.7% were discharged on aspirin. In the main study group, warfarin treatm ent rates increased with each consecutive triennial period (29.7%, 53.6%, a nd 77.1%, respectively; P=0.001). Age >80 years, poor command of Hebrew, an d being hospitalized in a given medical department emerged as independent v ariables negatively influencing warfarin use: P=0.0001, OR 0.30 (95% CI0.17 to 0.55);P=0.02, OR 0.59 (95% CI 0.36 to 0.94); and P=0.0002, OR 0.26 (95% CI 0.12 to 0.52), respectively. In contrast, past history of stroke and av ailability of echocardiographic information, regardless of the findings, ea ch increased warfarin use (P=0.03, OR 1.95 [95% CI 1.04 to 3.68], and P=0.0 001, OR 3.52 [95% CI 2.16 to 5.72], respectively). Conclusions-Old age, language difficulties, insufficient doctor alertness t o warfarin benefit, and patient disability produced reluctance to treat. Wa rfarin use still lags behind requirements.