Warfarin for non-valvar atrial fibrillation: still underused in the 21st century? | Heart

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Warfarin for non-valvar atrial fibrillation: still underused in the 21st century?

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Use of anticoagulation for non-valvar atrial fibrillation: comparison between two patient cohorts.
Theofilos M. Kolettis
Published on: 23 June 2003

Published on: 23 June 2003

Use of anticoagulation for non-valvar atrial fibrillation: comparison between two patient cohorts.

Theofilos M. Kolettis, MD
Other Contributors:
- John Goudevenos

Dear Editor

We read with great interest the article recently published in "Heart" on the current use of anticoagulation for non-valvar atrial fibrillation [1].

This article analyses the use of aspirin and anticoagulant treatment in 313 consecutive patients, presented with chronic atrial fibrillation of non-valvar etiology, in a single hospital in Northern Italy, from January 1 to June 30 2000. From th...

Dear Editor

We read with great interest the article recently published in "Heart" on the current use of anticoagulation for non-valvar atrial fibrillation [1].

This article analyses the use of aspirin and anticoagulant treatment in 313 consecutive patients, presented with chronic atrial fibrillation of non-valvar etiology, in a single hospital in Northern Italy, from January 1 to June 30 2000. From this cohort, 168 patients with no contraindications to anticoagulation were identified. These patients were classified as being at high risk for embolic stroke, hence anticoagulation was indicated according to recent guidelines.[2] Bo et al. [1] reported appropriate use of warfarin therapy in only 75 (44%) of patients, with a substantial proportion (42%) receiving subtherapeutic dosage. Furthermore, the use of anticoagulation declined with increasing age, despite the greater net benefit of such use in older patients.

Our group has previously reported on 628 patients presenting with non -valvar atrial fibrillation in the region of North-Western Greece (representing mostly rural areas) from March 1 to November 1 1998.[3] We thought that the similarities in the patient population characteristics, as well as the inclusion and exclusion criteria, enable a useful comparison between the two studies.

In our patient population,[3] of the 628 patients, 188 (29.9%) were excluded from the analysis by criteria similar to those used by Bo et al [1]. Of the 440 remaining patients, 328 (74.5%) were classified as being at high risk for embolic stroke, and of them, 95 (29%) were on anticoagulant therapy, 133 (40.5%) on aspirin and 100 (30.5%) on neither treatment. In concert with the results reported by Bo et al,[1] a subtherapeutic dose was given in 50% of our patients, and the use of anticoagulation declined with increasing age. We attempted to compare the use of anticoagulation and aspirin in the two patient cohorts, using chi-square.

Study	Anticoag.	Aspirin	None	Sum
Italian [1]	75	54	39	168
Greek [3]	95	133	100	328
Sum	170	187	139	496

Chi square= 12.42, p<_0.01 p="p"/> This comparison reinforces the conclusions drawn by Bo et al.[1] Anticoagulation treatment for non-valvar atrial fibrillation is substantially underused, especially in older patients, with therapeutic doses being achieved in only approximately half of the patients. Furthermore, these limitations appear even more prominent in rural areas, most likely due to additional difficulties in monitoring international normalized ratio (INR) values, compared to urban areas.

References

(1) Bo S, Ciccone G, Scaglione L, Taliano C, Piobbici M, Mereletti F, Pagano G. Warfarin for non-valvar atrial fibrillation: still underused in the 21st century? Heart 2003;89:553-554.

(2) Scottish Intercollegiate Guidelines Network (SIGN). Antithrombotic therapy. A national guideline. Edinburgh: SIGN, 1999, SIGN publication number 36.

(3) Patsouras D, Vakalis I, Giogakas V, Kitsanou M, Sioros L, Oikonomidis K, Goudevenos J. Status of anticoagulation therapy for patients with atrial fibrillation in north-western Greece. Hellenic J Cardiol (Athens) 1998;39:237-245.

Conflict of Interest:
None declared.

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