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Cited by 153Atrial Fibrillation Management and OutcomesVenous Thromboembolism Diagnosis and ManagementAcute Ischemic Stroke Management

The DOI matches its Crossref record; 39 of the 40 references it cites were found in a registry or an index.

Outcomes in a Warfarin-Treated Population With Atrial Fibrillation

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Björck, Fredrik, Renlund, Henrik, Lip, Gregory Y. H., Wester, Per, Svensson, Peter J., Själander, Anders·2016·JAMA Cardiology
DOI 10.1001/jamacardio.2016.0199
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Abstract

IMPORTANCE: Vitamin K antagonist (eg, warfarin) use is nowadays challenged by the non-vitamin K antagonist oral anticoagulants (NOACs) for stroke prevention in atrial fibrillation (AF). NOAC studies were based on comparisons with warfarin arms with times in therapeutic range (TTRs) of 55.2% to 64.9%, making the results less credible in health care systems with higher TTRs. OBJECTIVES: To evaluate the efficacy and safety of well-managed warfarin therapy in patients with nonvalvular AF, the risk of complications, especially intracranial bleeding, in patients with concomitant use of aspirin, and the impact of international normalized ratio (INR) control. DESIGN, SETTING, AND PARTICIPANTS: A retrospective, multicenter cohort study based on Swedish registries, especially AuriculA, a quality register for AF and oral anticoagulation, was conducted. The register contains nationwide data, including that from specialized anticoagulation clinics and primary health care centers. A total of 40 449 patients starting warfarin therapy owing to nonvalvular AF during the study period were monitored until treatment cessation, death, or the end of the study. The study was conducted from January 1, 2006, to December 31, 2011, and data were analyzed between February 1 and November 15, 2015. Associating complications with risk factors and individual INR control, we evaluated the efficacy and safety of warfarin treatment in patients with concomitant aspirin therapy and those with no additional antiplatelet medications. EXPOSURES: Use of warfarin with and without concomitant therapy with aspirin. MAIN OUTCOMES AND MEASURES: Annual incidence of complications in association with individual TTR (iTTR), INR variability, and aspirin use and identification of factors indicating the probability of intracranial bleeding. RESULTS: Of the 40 449 patients included in the study, 16 201 (40.0%) were women; mean (SD) age of the cohort was 72.5 (10.1) years, and the mean CHA2DS2-VASc (cardiac failure or dysfunction, hypertension, age ≥75 years [doubled], diabetes mellitus, stroke [doubled]-vascular disease, age 65-74 years, and sex category [female]) score was 3.3 at baseline. The annual incidence, reported as percentage (95% CI) of all-cause mortality was 2.19% (2.07-2.31) and, for intracranial bleeding, 0.44% (0.39-0.49). Patients receiving concomitant aspirin had annual rates of any major bleeding of 3.07% (2.70-3.44) and thromboembolism of 4.90% (4.43-5.37), and those with renal failure were at higher risk of intracranial bleeding (hazard ratio, 2.25; 95% CI, 1.32-3.82). Annual rates of any major bleeding and any thromboembolism in iTTR less than 70% were 3.81% (3.51-4.11) and 4.41% (4.09-4.73), respectively, and, in high INR variability, were 3.04% (2.85-3.24) and 3.48% (3.27-3.69), respectively. For patients with iTTR 70% or greater, the level of INR variability did not alter event rates. CONCLUSIONS AND RELEVANCE: Well-managed warfarin therapy is associated with a low risk of complications and is still a valid alternative for prophylaxis of AF-associated stroke. Therapy should be closely monitored for patients with renal failure, concomitant aspirin use, and poor INR control.

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Metadata

Authors
Björck, F., Renlund, H., Lip, G. Y. H., Wester, P., Svensson, P. J., & Själander, A.
Affiliations
  • Umeå University (SE)
  • Uppsala University (SE)
  • University of Birmingham (GB)
  • Danderyds sjukhus (SE)
  • Lund University (SE)
Corresponding author
Björck, Fredrik
ORCID
Venue
JAMA Cardiology
Publisher
American Medical Association (AMA)
Published
2016-05-01
Volume
1
Issue
2
Pages
172
ISSN
2380-6583 (ISSN-L)
DOI
10.1001/jamacardio.2016.0199
OpenAlex
W2338123562
Cited by
153
References
40
Citations by year
2026: 8 · 2025: 7 · 2024: 12 · 2023: 7 · 2022: 11 · 2021: 14 · 2020: 15 · 2019: 21 · 2018: 23 · 2017: 22 · 2016: 13
FWCI
21.72
Type
journal article
Language
en
Open access
Locations
  • JAMA Cardiology (publishedVersion)
  • PubMed (publishedVersion)
  • VBN Forskningsportal (Aalborg Universitet) (submittedVersion, other-oa)
Topics
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
  • Health Sciences › Medicine › Internal Medicine › Venous Thromboembolism Diagnosis and Management
  • Health Sciences › Medicine › Clinical Neurology › Acute Ischemic Stroke Management
Keywords
warfarin, atrial fibrillation, non-valvular atrial fibrillation, time in therapeutic range, INR variability, aspirin, intracranial hemorrhage, stroke prevention, oral anticoagulation, antiplatelet therapy, bleeding risk, CHA2DS2-VASc score, direct oral anticoagulants, treatment outcomes, auricle
MeSH terms
Aged, Aged, 80 and over, Anticoagulants, Aspirin, Atrial Fibrillation, Female, Hemorrhage, Humans, Male, Middle Aged, Platelet Aggregation Inhibitors, Retrospective Studies, Risk Factors, Sweden, Thromboembolism, Warfarin, Treatment Outcome, International Normalized Ratio, Stroke

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