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Essentials in Primary Care Conference Wednesday, July 31, 2013 Current Use of Warfarin in Preventing Stroke: A Recent Meta-Analysis • Previous Hart Meta-analysis (Ann Int Med 1999) with Warfarin revealed stroke or systemic embolism event rate at 2.09% per year with only 2 of 6 trials with time in therapeutic range (TTR) above 60% • This updated meta-analysis included 8 Randomized trials (including RE-LY, ROCKET-AF, ARISTOTLE) with 32,053 patients • Overall INR was in therapeutic range (TTR) in 7 of the 8 trials more than 60% of the time • Incidence of stroke or systemic embolism now at 1.66% per year (down from 2.09% per year) with warfarin Rx with better TTR. TAKE AWAY POINT: • There has been a significant improvement using warfarin in the proportion of time spent in therapeutic anticoagulation with a resultant decline in observed stroke rates. Agarwal S, et al. Archives Intern Med 2012;172:623-631 Can We Make Warfarin Use Easier for the Patient? • Study: VKA patients on stable dose of warfarin for 6 months currently on monthly f/u (n=226) with stable INR • Intervention: f/u Q4 weeks vs Q 12 weeks • Outcome : TTR (4 wk vs 12 wk): 74.1% vs 72.6% (non inferior) Major bleeding, VTE, death: No difference Intervention: f/u Q4 weeks vs Q 12 weeks • Conclusion: Q 3 months f/up of warfarin monitoring is acceptable in a patient with a stable and therapeutic INR Schulman S, Ann Intern Med 2011;155:653-659 Jan Basile, MD Atrial Fibrillation & Stroke Prevention
Essentials in Primary Care Conference Wednesday, July 31, 2013 Antithrombotic Paradox in AF: The Greater The Stroke Risk, The Less The Anticoagulant Use Wolf PA. Arch Intern Med 1987;147:1561-4 White RH. Am J Med 1999;106:165-71 Why Warfarin Is Underutilized in Clinical Practice for Non-Valvular Atrial Fibrillation (NVAF) • Narrow Therapeutic Index Drug (INR 2.0-3.0 range; target 2.5) [Mechanical valves INR 3.0-4.0 range; target 3.5] • Drug-Drug Interactions • Food-Drug Interactions (Vit K containing foods) • Has Required frequent laboratory monitoring • Bleeding risk Bottom Line: • Up to 50% of NVAF patients are not taking an oral anticoagulant Jan Basile, MD Atrial Fibrillation & Stroke Prevention
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