Transcript GWTG HFSA Poster 2006 - American Heart Association

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.)
Results
• Patients with HF have increased risk for thrombotic events.
Exhibit 1. Baseline Characteristics of Patients
• However, the net clinical benefit of anticoagulation in a HF population in sinus rhythm has not been supported.
Variable
• The real-world prevalence and variation in warfarin prescription for HF patients in the absence of established indications is
unknown.
Exhibit 2. Factors associated with anticoagulation
No Anticoagulation
(N=58736)
69.0(57.0, 80.0)
50.0
Anticoagulation
(N=7404)
70.0 (57.0, 80.0)
45.1
P-value+
Age, median (25th, 75th), year
0.025
Female sex, %
<0.001
Race
White
56.9
61.2
<0.001
Black or African American
26.0
23.2
• Using data from the AHA’s Get With The Guidelines®-Heart Failure (GWTG-HF) Registry, we sought to determine the
Hispanic
8.9
7.4
prevalence and variation, as well as patient characteristics, in warfarin prescription among a real-world HF population.
Asian
1.7
1.0
Other
0.9
0.8
Unable to determine
2.4
2.1
Insurance, %
<0.001
Inclusion criteria
No Insurance/Not Documented
6.7
5.0
Medicare
43.3
43.2
• Patients discharged home from hospitals in the Get With The Guidelines-Heart Failure registry between January 1, 2005,
and September 30, 2011.
Medicaid
11.8
11.6
Other
27.6
28.4
Exclusion criteria
History of, %
• Contraindications to warfarin, history of AF, history of CVA/TIA, history of valvular heart disease, in-hospital valve surgery,
Diabetes
45.9
42.2
<0.001
in-hospital deaths, incomplete discharge data
Hyperlipidemia
42.4
41.0
0.034
Statistical analysis
Hypertension
76.8
69.5
<0.001
Peripheral vascular disease
9.8
11.2
0.003
• We compared patient and hospital characteristics among patients with and without anticoagulation prescription at
Coronary artery disease
45.3
48.8
<0.001
discharge.
Prior myocardial infarction
17.4
19.6
<0.001
• To evaluate hospital variation, we compared observed rates of anticoagulation at discharge for hospitals with 10 or more
Anemia
15.6
12.2
<0.001
patients
Long-term dialysis
5.0
2.9
<0.001
• Logistic regression models using the generalized estimating equation were developed to identify factors associated with
Chronic kidney disease
20.0
16.8
<0.001
warfarin prescription at discharge.
Smoking
22.3
18.5
<0.001
Ischemic etiology
50.2
53.7
<0.001
Ejection fraction < 35%
49.0
58.6
<0.001
Meds Prior to Admission, %
ACE inhibitor
41.2
43.5
0.001
• Findings from GWTG-HF hospitals may not be generalizable to all hospitals
Aldosterone antagonist
9.8
16.0
<0.001
• Data are dependent on the quality of medical record documentation and chart abstraction
Angiotensin receptor blocker
15.3
14.3
0.039
Aspirin
49.4
39.3
<0.001
• Indications not captured: ventricular thrombus, hypercoagulable state, prior thromboembolic events
Beta-Blocker
48.4
50.8
0.001
• Contraindications not captured: hemorrhagic tendencies, vascular aneurysm, recent procedures, blood dyscrasias,
Statin
43.9
45.7
0.011
pregnancy
In-hospital Procedures
ICD/CRT-D
7.1
8.8
<0.001
CABG
0.5
0.5
0.484
PTCA
1.8
1.1
<0.001
• Warfarin was prescribed at discharge in more than 1 out of 10 HF patients without evident indications or contraindications
Hospital Characteristics
for anticoagulation
No. of beds in hospital, median (IQR)
392 (265, 580)
392 (270,581)
0.040
Teaching status
59.3
57.9
<0.001
• Prescription rates vary widely across hospitals
Primary PTCA performed for AMI
79.9
77.8
0.002
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 fromCardiac
the American
Heart Association
Pharmaceutical Roundtable, David and Stevie Spina, and an American
Cardiology Young Investigator Database
surgery
performed
72.2 Heart Association Council on Clinical70.9
0.040
Objectives
Methods
Limitations
Conclusions
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.
Adjusted Odds Ratio
(95% Confidence Interval)
1.77 (1.63-1.91)
1.21 (1.10-1.33)
1.11 (1.02-1.20)
1.07 (1.01-1.14)
1.02 (1.01-1.03)
1.02 (1.01-1.03)
0.97 (0.96-0.98)
0.95 (0.94-0.95)
0.93 (0.88-0.99)
0.91 (0.83-0.99)
0.91 (0.85-0.97)
0.85 (0.77-0.94)
0.84 (0.77-0.91)
0.82 (0.75-0.90)
0.81 (0.71-0.93)
0.77 (0.65-0.92)
0.72 (0.66-0.78)
Variable
Prior ICD or CRT-D implantation
Peripheral vascular disease
History of ischemic heart disease
Male
Ejection fraction, per 5 % decrease
Heart rate, per 5 bpm
Age, per 5 years
Systolic blood pressure, per 5 mmHg
Dyslipidemia
Anemia
Diabetes mellitus
Race: Other (reference: white race)
Hypertension
Chronic kidney disease
Lack of health insurance (reference: private insurance)
End-stage renal disease requiring dialysis
Smoking history
Exhibit 3. Site-level variation in anticoagulation
45
40
% Subjects prescribed warfarin at discharge
Background
35
30
25
20
15
10
5
0
Sites
Contact
Zubin J. Eapen, MD; Duke Clinical Research Institute,
Durham, NC 27705; [email protected]