Warfarin for atrial fibrillation in community-based practise

Background: Previous studies of anticoagulation for atrial fibrillation (AF) have predominantly occurred in academic settings or randomized trials, limiting their generalizability. Objective: To describe the management of patients with AF anticoagulated with warfarin in community-based practise. Methods: We enrolled 3396 patients from 101 community-based practises in 38 states. Data included demographics, comorbidities, and International Normalized Ratio (INR) values. Outcomes included time in therapeutic INR range (TTR), stroke, and major hemorrhage. Results: The mean TTR was 66.5%, but varied widely among patients: 37% had TTR above 75%, while 34% had TTR below 60%. The yearly rates of major hemorrhage and stroke were 1.90 per 100 person-years and 1.00 per 100 person-years. Four percent of patients (n=127) were intentionally targeted to a lower INR, and spent 42.7% of time with an INR below 2.0, compared to 18.8% for patients with a 2.0-3.0 range (P<0.001). Mean TTR for new warfarin users (57.5%) remained below that of prevalent users through the first sixmonths. Patients with interruptions of warfarin therapy had lower TTR than all others (61.6% vs. 67.2%, P<0.001), which corrected after deleting low peri-procedural INR values (67.0% vs. 67.4%, P=0.73). Conclusions: Anticoagulation control varies widely among patients taking warfarin for AF. TTR is affected by new warfarin use, procedural interruptions, and INR target range. In this community-based cohort of predominantly prevalent warfarin users, rates of hemorrhage and stroke were low. The risk versus benefit of a lower INR target range to offset bleeding risk remains uncertain.