• Patients with HF have increased risk for thrombotic events.

• However, the net clinical benefit of anticoagulation in a HF population in sinus rhythm has not been supported.

• The real-world prevalence and variation in warfarin prescription for HF patients in the absence of established indications is unknown.

Background

Objectives• Using data from the AHA’s Get With The Guidelines®-Heart Failure (GWTG-HF) Registry, we sought to determine the prevalence and variation, as well as patient characteristics, in warfarin prescription among a real-

world HF population.

MethodsInclusion criteria

• Patients discharged home from hospitals in the Get With The Guidelines-Heart Failure registry between January 1, 2005, and September 30, 2011.

Exclusion criteria

• Contraindications to warfarin, history of AF, history of CVA/TIA, history of valvular heart disease, in-hospital valve surgery, in-hospital deaths, incomplete discharge data

Statistical analysis

• We compared patient and hospital characteristics among patients with and without anticoagulation prescription at discharge.

• To evaluate hospital variation, we compared observed rates of anticoagulation at discharge for hospitals with 10 or more patients

• Logistic regression models using the generalized estimating equation were developed to identify factors associated with warfarin prescription at discharge.

Results

Conclusions• Warfarin was prescribed at discharge in more than 1 out of 10 HF patients without evident indications or contraindications for anticoagulation

• Prescription rates vary widely across hospitals

Prescribing Warfarin at Discharge for Heart Failure Patients:

Findings from the Get With The Guidelines-Heart Failure Registry Zubin J. Eapen, Maria Grau-Sepulveda, Gregg C. Fonarow, Paul A. Heidenreich, Eric D. Peterson, Adrian F. Hernandez

From the Duke Clinical Research Institute, Durham, NC (Z.J.E, M.G., E.D.P., A.F.H.), University of California Los Angeles, Los Angeles, CA (G.C.F.), Palo Alto VA Medical Center, Palo Alto, California (P.A.H.)

Exhibit 1. Baseline Characteristics of Patients Exhibit 2. Factors associated with anticoagulation

Exhibit 3. Site-level variation in anticoagulation

Contact

Zubin J. Eapen, MD; Duke Clinical Research Institute,

Durham, NC 27705; zubin.eapen@duke.edu

Disclosures – ZJE, MG, PAH: no relevant disclosures; GCF:research support from the NHLBI and AHRQ (both significant), consulting for Novartis (significant), Gambro (significant), and Medtronic (modest) ; EDP,:co-principal investigators of the Data Analytic Center for AHA GWTG Program, AH: research support from the NHLBI, AHRQ, Amylin, Johnson & Johnson, Portola Pharmaceuticals (significant), consulting for Astra Zeneca (Modest), Corthera (significant), Sanofi (modest) and Bristol Myers Squib (modest). Funding Source – This work was supported by an award from the American Heart Association Pharmaceutical Roundtable, David and Stevie Spina, and an

American Heart Association Council on Clinical Cardiology Young Investigator Database Research Seed Grant. This project was also supported in part by grant number U19HS021092 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not represent the official views of the Agency for Healthcare Research and Quality.

Limitations• Findings from GWTG-HF hospitals may not be generalizable to all hospitals

• Data are dependent on the quality of medical record documentation and chart abstraction

• Indications not captured: ventricular thrombus, hypercoagulable state, prior thromboembolic events

• Contraindications not captured: hemorrhagic tendencies, vascular aneurysm, recent procedures, blood dyscrasias, pregnancy

Variable No Anticoagulation(N=58736)

Anticoagulation(N=7404)

P-value+

Age, median (25th, 75th), year 69.0(57.0, 80.0) 70.0 (57.0, 80.0) 0.025Female sex, % 50.0 45.1 <0.001Race      

White 56.9 61.2 <0.001Black or African American 26.0 23.2  Hispanic 8.9 7.4  Asian 1.7 1.0  Other 0.9 0.8  Unable to determine 2.4 2.1  

Insurance, %     <0.001No Insurance/Not Documented 6.7 5.0  Medicare 43.3 43.2  Medicaid 11.8 11.6  Other 27.6 28.4  

History of, %      Diabetes 45.9 42.2 <0.001Hyperlipidemia 42.4 41.0 0.034Hypertension 76.8 69.5 <0.001Peripheral vascular disease 9.8 11.2 0.003Coronary artery disease 45.3 48.8 <0.001Prior myocardial infarction 17.4 19.6 <0.001Anemia 15.6 12.2 <0.001Long-term dialysis 5.0 2.9 <0.001Chronic kidney disease 20.0 16.8 <0.001Smoking 22.3 18.5 <0.001Ischemic etiology 50.2 53.7 <0.001Ejection fraction < 35% 49.0 58.6 <0.001

Meds Prior to Admission, %      ACE inhibitor 41.2 43.5 0.001Aldosterone antagonist 9.8 16.0 <0.001Angiotensin receptor blocker 15.3 14.3 0.039Aspirin 49.4 39.3 <0.001Beta-Blocker 48.4 50.8 0.001Statin 43.9 45.7 0.011

In-hospital Procedures      ICD/CRT-D 7.1 8.8 <0.001CABG 0.5 0.5 0.484PTCA 1.8 1.1 <0.001

Hospital Characteristics      No. of beds in hospital, median (IQR) 392 (265, 580) 392 (270,581) 0.040Teaching status 59.3 57.9 <0.001Primary PTCA performed for AMI 79.9 77.8 0.002Cardiac surgery performed 72.2 70.9 0.040Heart transplants performed 9.1 11.7 <0.001

Variable Adjusted Odds Ratio(95% Confidence Interval)

Prior ICD or CRT-D implantation 1.77 (1.63-1.91)Peripheral vascular disease 1.21 (1.10-1.33)History of ischemic heart disease 1.11 (1.02-1.20)Male 1.07 (1.01-1.14)Ejection fraction, per 5 % decrease 1.02 (1.01-1.03)Heart rate, per 5 bpm 1.02 (1.01-1.03)Age, per 5 years 0.97 (0.96-0.98)Systolic blood pressure, per 5 mmHg 0.95 (0.94-0.95)Dyslipidemia 0.93 (0.88-0.99)Anemia 0.91 (0.83-0.99)Diabetes mellitus 0.91 (0.85-0.97)Race: Other (reference: white race) 0.85 (0.77-0.94)Hypertension 0.84 (0.77-0.91)Chronic kidney disease 0.82 (0.75-0.90)Lack of health insurance (reference: private insurance) 0.81 (0.71-0.93)End-stage renal disease requiring dialysis 0.77 (0.65-0.92)Smoking history 0.72 (0.66-0.78)

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