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TIME IN THERAPEUTIC RANGE PREDICTS MORTALITY AND CEREBROVASCULAR EVENTS IN ATRIAL FIBRILLATION PATIENTS TREATED WITH WARFARIN
501 JACC March 21, 2017 Volume 69, Issue 11
Arrhythmias and Clinical EP TIME IN THERAPEUTIC RANGE PREDICTS MORTALITY AND CEREBROVASCULAR EVENTS IN ATRIAL FIBRILLATION PATIENTS TREATED WITH WARFARIN Poster Contributions Poster Hall, Hall C Saturday, March 18, 2017, 3:45 p.m.-4:30 p.m. Session Title: Innovative Approaches for Reducing Risk and Improving Outcomes With Ablation Abstract Category: 8. Arrhythmias and Clinical EP: Supraventricular/Ventricular Arrhythmias Presentation Number: 1237-108 Authors: Malini Madhavan, Suraj Kapa, Veronique Roger, Susan Weston, Jill M. Killian, Samuel Asirvatham, Bernard Gersh, Alanna Chamberlain, Mayo Clinic, Rochester, MN, USA
Background: Time in therapeutic range (TTR) (INR 2 - 3) indicates efficacy of warfarin anticoagulation in atrial fibrillation (AF) patients. Whether it predicts outcomes in the community is not known.
Methods: A community-based cohort of incident AF in Olmsted County, MN residents ≥18 y between 2000 - 2013 was identified using diagnostic codes and validated using ECGs and the medical record. TTR was calculated by interpolation between INR values and divided into tertiles.The association between outcomes (stroke/TIA and death) and TTR was examined using multivariable Cox regression adjusting for age, CHA2DS2-VASc score and Charlson comorbidity index.
Results: 4431 patients with incident AF were identified (mean age 72.5±14.6, 53.2% men). The median (IQR) CHA2DS2-VASc score was 3 (2-5) and the Charlson comorbidity index was 1 (0-3). Warfarin was initiated in 60.8% of patients with mean TTR of 51.3±27.7%. Over a mean follow-up of 4.6 years, 431 (9.7%) patients experienced a stroke/TIA and 2170 (49%) died. When compared to the highest tertile of TTR, those with lower tertiles of TTR and those not on anticoagulation had higher risks of stroke/TIA and death (Table).
Conclusions: Community dwelling AF patients on warfarin with TTR <69% demonstrated risk of stroke/TIA and death similar to or greater than those not treated with warfarin. A systematic approach to improving efficacy of warfarin anticoagulation should be a priority. The role of direct oral anticoagulants in AF with low TTR needs further investigation. Association of warfarin use and time in therapeutic range (TTR) with outcomes in AF All-cause mortality Hazard ratio (95% CI) Stroke/TIA Hazard ratio (95% CI) 3.28 (2.74-3.92) 2.62 (1.80-3.80)
No warfarin Warfarin TTR tertile 1 (0 ≤ TTR ≤ 35.0%) TTR tertile 2 (35.0% < TTR ≤ 69.04%) TTR tertile 3 (69.04% < TTR ≤ 100%)
11.48 (9.15-14.40) 2.80 (2.30-3.41) 1.00
7.48 (4.51-12.40) 2.12 (1.38-3.28) 1.00
Arrhythmias and Clinical EP TIME IN THERAPEUTIC RANGE PREDICTS MORTALITY AND CEREBROVASCULAR EVENTS IN ATRIAL FIBRILLATION PATIENTS TREATED WITH WARFARIN Poster Contributions Poster Hall, Hall C Saturday, March 18, 2017, 3:45 p.m.-4:30 p.m. Session Title: Innovative Approaches for Reducing Risk and Improving Outcomes With Ablation Abstract Category: 8. Arrhythmias and Clinical EP: Supraventricular/Ventricular Arrhythmias Presentation Number: 1237-108 Authors: Malini Madhavan, Suraj Kapa, Veronique Roger, Susan Weston, Jill M. Killian, Samuel Asirvatham, Bernard Gersh, Alanna Chamberlain, Mayo Clinic, Rochester, MN, USA
Background: Time in therapeutic range (TTR) (INR 2 - 3) indicates efficacy of warfarin anticoagulation in atrial fibrillation (AF) patients. Whether it predicts outcomes in the community is not known.
Methods: A community-based cohort of incident AF in Olmsted County, MN residents ≥18 y between 2000 - 2013 was identified using diagnostic codes and validated using ECGs and the medical record. TTR was calculated by interpolation between INR values and divided into tertiles.The association between outcomes (stroke/TIA and death) and TTR was examined using multivariable Cox regression adjusting for age, CHA2DS2-VASc score and Charlson comorbidity index.
Results: 4431 patients with incident AF were identified (mean age 72.5±14.6, 53.2% men). The median (IQR) CHA2DS2-VASc score was 3 (2-5) and the Charlson comorbidity index was 1 (0-3). Warfarin was initiated in 60.8% of patients with mean TTR of 51.3±27.7%. Over a mean follow-up of 4.6 years, 431 (9.7%) patients experienced a stroke/TIA and 2170 (49%) died. When compared to the highest tertile of TTR, those with lower tertiles of TTR and those not on anticoagulation had higher risks of stroke/TIA and death (Table).
Conclusions: Community dwelling AF patients on warfarin with TTR <69% demonstrated risk of stroke/TIA and death similar to or greater than those not treated with warfarin. A systematic approach to improving efficacy of warfarin anticoagulation should be a priority. The role of direct oral anticoagulants in AF with low TTR needs further investigation. Association of warfarin use and time in therapeutic range (TTR) with outcomes in AF All-cause mortality Hazard ratio (95% CI) Stroke/TIA Hazard ratio (95% CI) 3.28 (2.74-3.92) 2.62 (1.80-3.80)
No warfarin Warfarin TTR tertile 1 (0 ≤ TTR ≤ 35.0%) TTR tertile 2 (35.0% < TTR ≤ 69.04%) TTR tertile 3 (69.04% < TTR ≤ 100%)
11.48 (9.15-14.40) 2.80 (2.30-3.41) 1.00
7.48 (4.51-12.40) 2.12 (1.38-3.28) 1.00