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Net clinical benefit of warfarin in individuals with atrial fibrillation across stroke risk and across primary and secondary care
  1. Victoria Allan,
  2. Amitava Banerjee,
  3. Anoop Dinesh Shah,
  4. Riyaz Patel,
  5. Spiros Denaxas,
  6. Juan-Pablo Casas,
  7. Harry Hemingway
  1. Farr Institute of Health Informatics Research, Institute of Health Informatics, University College London, London, UK
  1. Correspondence to Professor Harry Hemingway, Farr Institute of Health Informatics Research, University College London, 222 Euston Road, London NW1 2AD, UK; h.hemingway{at}


Objective To investigate net clinical benefit (NCB) of warfarin in individuals with atrial fibrillation (AF) across stroke risk and across primary and secondary care.

Methods We conducted a linked electronic health record cohort study of 70 206 individuals with initial record of diagnosis of AF in primary (n=29 568) or secondary care (n=40 638) in England (1998–2010). We defined stroke risk according to the CHA2DS2-VASc score, and followed individuals over a median 2.2 years for 7005 ischaemic strokes (IS) and for 906 haemorrhagic strokes (HS). We calculated incidence rates (IRs) and 95% CIs per 100 person-years (PYs) (IR (95% CI)/100 PY) of IS and HS, with and without use of warfarin, and the NCB (ie, number of IS avoided) per 100 PYs of warfarin use (NCB (95% CI)/100 PY).

Results Compared with individuals with initial record of diagnosis in secondary care, those in primary care had lower scores of IS risk (CHA2DS2-VASc≤2: 30.8% vs 20.6%), and lower overall incidence of IS (IR (95% CI)/100 PY: 2.3 (2.2 to 2.4) vs 4.3 (4.2 to 4.4), p value=0.00); however among individuals with CHA2DS2-VASc=0, 1 or 2 there were no differences in IS rate between those with initial record of diagnosis in primary care or secondary care (IR (95% CI)/100 PY: 0.2 (0.1 to 0.3) vs 0.3 (0.2 to 0.5), p value=0.16), (IR (95% CI)/100 PY: 0.6 (0.4 to 0.7) vs 0.7 (0.6 to 0.9), p value=0.08) and (IR (95% CI)/100 PY: 1.1 (1.00 to 1.3) vs 1.4 (1.2 to 1.6), p value=0.05), respectively. For CHA2DS2-VASc=0, 1 and 2, IRs of IS with versus without warfarin were (IR (95% CI)/100 PY: 0.4 (0.2 to 0.8) vs 0.2 (0.1 to 0.3), p value=0.16), (IR (95% CI)/100 PY: 0.4 (0.3 to 0.7) vs 0.7 (0.6 to 0.8), p value=0.03) and (IR (95% CI)/100 PY: 0.8 (0.7 to 1.0) vs 1.4 (1.3 to 1.6), p value=0.00), respectively. We found a significant positive NCB of warfarin from CHA2DS2-VASc≥2 in men (NCB (95% CI)/100 PY: 0.5 (0.1 to 0.9)) and from CHA2DS2-VASc≥3 in women (NCB (95% CI)/100 PY: 1.5 (1.1 to 1.9)).

Conclusions CHA2DS2-VASc accurately stratifies IS risk in individuals with AF across both primary and secondary care. However, the incidence rate of ischaemic stroke at CHA2DS2-VASc=1 are lower than previously reported, which may change the decision to start anticoagulation with warfarin in these individuals.

  • Stroke

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  • Twitter Follow Victoria Allan at @victoriaallanuk and Amitava Banerjee at @amibanerjee1

  • Contributors VA analysed and interpreted the data, and drafted the manuscript. HH led the study as principal investigator. AB contributed to interpretation of results and drafting of manuscript. ADS and RP contributed to the data analysis. SD extracted and validated the data. AB, ADS, HH, J-PC, RP and SD critically reviewed drafts of the manuscript, and approved the final version.

  • Funding This project was supported by the European Society of Cardiology, and the 10 funders of the Farr Institute of Health Informatics Research: The Medical Research Council (K006584/1) in partnership with Arthritis Research UK, the British Heart Foundation, Cancer Research UK, the Economic and Social Research Council, the Engineering and Physical Sciences Research Council, the NIHR, the National Institute for Social Care and Health Research (Welsh Assembly Government), the Chief Scientist Office (Scottish Government Health Directorates) and the Wellcome Trust.

  • Competing interests None declared.

  • Ethics approval CALIBER has received Ethics approval (ref: 09/H0810/16) and Ethics and Confidentiality Committee of the National Information Governance Board for Health and Social Care approval (ref: ECC 2-06(b)/2009 CALIBER data set).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement CALIBER data can be accessed on application.

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