Outcomes Associated With Warfarin Use in Older Patients With Heart Failure and Atrial Fibrillation and a Cardiovascular Implantable Electronic Device: Findings From the ADHERE Registry Linked to Medicare Claims

Authors

  • Paul L. Hess MD,

    1. Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
    2. Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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  • Melissa A. Greiner MS,

    1. Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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  • Gregg C. Fonarow MD,

    1. Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, California
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  • Winslow Klaskala PhD, MS,

    1. Janssen Pharmaceutical Research and Development, LLC, Raritan, New Jersey
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  • Roger M. Mills MD,

    1. Janssen Pharmaceutical Research and Development, LLC, Raritan, New Jersey
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  • Soko Setoguchi MD, DrPH,

    1. Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
    2. Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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  • Sana M. Al-Khatib MD, MHS,

    1. Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
    2. Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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  • Adrian F. Hernandez MD, MHS,

    1. Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
    2. Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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  • Lesley H. Curtis PhD

    Corresponding author
    1. Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
    2. Department of Medicine, Duke University School of Medicine, Durham, North Carolina
    • Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715
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Abstract

Background:

Warfarin use and associated outcomes in patients with heart failure and atrial fibrillation and a cardiovascular implantable electronic device have not been described previously.

Hypothesis:

We hypothesized that warfarin is underused and is associated with lower risks of mortality, thromboembolic events, and myocardial infarction.

Methods:

Using data from a clinical registry linked with Medicare claims, we examined warfarin use at discharge and 30-day and 1-year Kaplan-Meier estimates of all-cause mortality and cumulative incidence rates of mortality, thromboembolic events, myocardial infarction, and bleeding events in patients 65 years or older, with a history of atrial fibrillation and a cardiovascular implantable electronic device admitted with heart failure between 2001 and 2006, who were naïve to anticoagulation therapy at admission. We compared outcomes between patients who were or were not prescribed warfarin at discharge and tested associations between treatment and outcomes.

Results:

Of 2586 eligible patients in 252 hospitals, 2049 were discharged without a prescription for warfarin. At 1 year, the group discharged without warfarin had a higher mortality rate after discharge (37.4% vs 28.8%; P < 0.001) but similar rates of thromboembolism, myocardial infarction, and bleeding events. After adjustment, treatment with warfarin was associated with lower risk of all-cause death 1 year after discharge (hazard ratio: 0.76, 95% confidence interval: 0.63–0.92).

Conclusions:

Among older patients with heart failure and atrial fibrillation and a cardiovascular implantable electronic device, 4 of 5 were discharged without a prescription for warfarin. Warfarin nonuse was associated with a higher risk of death 1 year after discharge. Clin. Cardiol. 2011 DOI: 10.1002/clc.22064

Damon M. Seils, MA, Duke University, assisted with manuscript preparation. Mr. Seils did not receive compensation for his assistance apart from his employment at the institution where the study was conducted.

This study was supported by a research agreement between Duke University and Janssen Pharmaceuticals.

The authors have no other funding, financial relationships, or conflicts of interest to disclose.

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