Elevated Amyloid-β PET Scan and Cognitive and Functional Decline in Mild Cognitive Impairment and Dementia of Uncertain Etiology

BACKGROUND

Elevated amyloid-β (Aβ) on positron emission tomography (PET) scan is used to aid diagnosis of Alzheimer's disease (AD), but many prior studies have focused on patients with a typical AD phenotype such as amnestic mild cognitive impairment (MCI). Little is known about whether elevated Aβ on PET scan predicts rate of cognitive and functional decline among those with MCI or dementia that is clinically less typical of early AD, thus leading to etiologic uncertainty.

OBJECTIVE

We aimed to investigate whether elevated Aβ on PET scan predicts cognitive and functional decline over an 18-month period in those with MCI or dementia of uncertain etiology.

METHODS

In 1,028 individuals with MCI or dementia of uncertain etiology, we evaluated the association between elevated Aβ on PET scan and change on a telephone cognitive status measure administered to the participant and change in everyday function as reported by their care partner.

RESULTS

Individuals with either MCI or dementia and elevated Aβ (66.6% of the sample) showed greater cognitive decline compared to those without elevated Aβ on PET scan, whose cognition was relatively stable over 18 months. Those with either MCI or dementia and elevated Aβ were also reported to have greater functional decline compared to those without elevated Aβ, even though the latter group showed significant care partner-reported functional decline over time.

CONCLUSIONS

Elevated Aβ on PET scan can be helpful in predicting rates of both cognitive and functional decline, even among cognitively impaired individuals with atypical presentations of AD.

Risk of Atherosclerotic Cardiovascular Disease Hospitalizations after COPD Hospitalization among Older Adults

BACKGROUND

Meta-analyses have suggested the risk of atherosclerotic cardiovascular disease (ASCVD) events is significantly higher after a chronic obstructive pulmonary disease (COPD) exacerbation. However, these studies have been limited to highly selected patient populations potentially not generalizable to the broader population of COPD.

METHODS

We assessed the risk of ASCVD hospitalizations after COPD hospitalization compared to before COPD hospitalization and identified patient factors associated with ASCVD hospitalizations after COPD hospitalization. This retrospective cohort study used claims data from 920,550 Medicare beneficiaries hospitalized for COPD from 2016-2019 in the US. The primary outcome was risk of a ASCVD hospitalization composite outcome (myocardial infarction, percutaneous coronary intervention, coronary artery by-pass graft surgery, stroke, or transient ischemic attack) in the 1 year after-COPD hospitalization relative to the 1 year before-COPD hospitalization. Time from discharge to a composite ASCVD hospitalization outcome was modeled using an extension of the Cox Proportional-Hazards model, the Anderson-Gill model with adjustment for patient characteristics. Additional analyses evaluated for interactions in subgroups and risk factors associated with the composite ASCVD hospitalization outcome.

RESULTS

Among 920,550 patients (mean age, 73 years) the hazard ratio estimate (HR; 95% CI) for the composite ASCVD hospitalization outcome after-COPD hospitalization vs before-COPD hospitalization was 0.99 (0.97, 1.02; p = 0.53) following adjustment. We observed 3 subgroups that were significantly associated with higher risk for ASCVD hospitalizations after COPD hospitalization: 76+ years old, women, COPD hospitalization severity. Among the 19 characteristics evaluated, 10 were significantly associated with higher risk of CVD events 1 year after COPD hospitalization with hyperlipidemia (2.78; 2.67, 2.90) and history of cardiovascular disease (1.77; 1.72 1.83) associated with the greatest risk.

CONCLUSION

Among Medicare beneficiaries hospitalized for COPD, the risk of ASCVD hospitalizations was not significantly increased after COPD-hospitalization relative to before-COPD hospitalization. Although, we identified age 76+ years old, female sex, and COPD hospitalization severity as high risk subgroups and 10 risk factors associated with increased risk of ASCVD events after-COPD hospitalization. Further research is needed to characterize the COPD exacerbation populations at highest ASCVD hospitalization risk.

Post-traumatic stress disorder symptoms among healthcare workers during the COVID-19 pandemic: Analysis of the HERO Registry

Little is known about the mental health consequences of the COVID-19 pandemic in healthcare workers (HCWs). Past literature has shown that chronic strain caused by pandemics can adversely impact a variety of mental health outcomes in HCWs. There is growing recognition of the risk of stress and loss of resilience to HCWs during the COVID-19 pandemic, although the risk of post-traumatic stress disorder (PTSD) symptoms in HCWs during the COVID-19 pandemic remains poorly understood. We wanted to understand the relationship between the COVID-19 pandemic and the risk of PTDS symptoms in HCWs during the COVID-19 pandemic. We surveyed 2038 health care workers enrolled in the Healthcare Worker Exposure Response & Outcomes (HERO) study, which is a large standardized national registry of health care workers. Participants answered questions about demographics, COVID-19 exposure, job burnout, and PTSD symptoms. We characterize the burden of PTSD symptoms among HCWs, and determined the association between high PTSD symptoms and race, gender, professional role, work setting, and geographic region using multivariable regression. In a fully adjusted model, we found that older HCWs were less likely to report high PTSD symptoms compared with younger HCWs. Additionally, we found that physicians were less likely to report high PTSD symptoms compared with nurses. These data add to the growing literature on increased risks of mental health challenges to healthcare workers during the COVID-19 pandemic.

Potential bias and lack of generalizability in electronic health record data: reflections on health equity from the National Institutes of Health Pragmatic Trials Collaboratory

Embedded pragmatic clinical trials (ePCTs) play a vital role in addressing current population health problems, and their use of electronic health record (EHR) systems promises efficiencies that will increase the speed and volume of relevant and generalizable research. However, as the number of ePCTs using EHR-derived data grows, so does the risk that research will become more vulnerable to biases due to differences in data capture and access to care for different subsets of the population, thereby propagating inequities in health and the healthcare system. We identify 3 challenges-incomplete and variable capture of data on social determinants of health, lack of representation of vulnerable populations that do not access or receive treatment, and data loss due to variable use of technology-that exacerbate bias when working with EHR data and offer recommendations and examples of ways to actively mitigate bias.

Gender and intention to leave healthcare during the COVID-19 pandemic among U.S. healthcare workers: A cross sectional analysis of the HERO registry

IMPORTANCE

The COVID-19 pandemic stressed the healthcare field, resulting in a worker exodus at the onset and throughout the pandemic and straining healthcare systems. Female healthcare workers face unique challenges that may impact job satisfaction and retention. It is important to understand factors related to healthcare workers' intent to leave their current field.

OBJECTIVE

To test the hypothesis that female healthcare workers were more likely than male counterparts to report intention to leave.

DESIGN

Observational study of healthcare workers enrolled in the Healthcare Worker Exposure Response and Outcomes (HERO) registry. After baseline enrollment, two HERO 'hot topic' survey waves, in May 2021 and December 2021, ascertained intent to leave. Unique participants were included if they responded to at least one of these survey waves.

SETTING

HERO registry, a large national registry that captures healthcare worker and community member experiences during the COVID-19 pandemic.

PARTICIPANTS

Registry participants self-enrolled online and represent a convenience sample predominantly composed of adult healthcare workers.

EXPOSURE(S)

Self-reported gender (male, female).

MAIN OUTCOME

Primary outcome was intention to leave (ITL), defined as having already left, actively making plans, or considering leaving healthcare or changing current healthcare field but with no active plans. Multivariable logistic regression models were performed to examine the odds of intention to leave with adjustment for key covariates.

RESULTS

Among 4165 responses to either May or December surveys, female gender was associated with increased odds of ITL (42.2% males versus 51.4% females reported intent to leave; aOR 1.36 [1.13, 1.63]). Nurses had 74% higher odds of ITL compared to most other health professionals. Among those who expressed ITL, three quarters reported job-related burnout as a contributor, and one third reported experience of moral injury.

CONCLUSIONS AND RELEVANCE

Female healthcare workers had higher odds of intent to leave their healthcare field than males. Additional research is needed to examine the role of family-related stressors.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT04342806.

Concordance Between Patient-Reported Health Data and Electronic Health Data in the ADAPTABLE Trial

Importance

Patient-reported health data can facilitate clinical event capture in pragmatic clinical trials. However, few data are available on the fitness for use of patient-reported data in large-scale health research.

Objective

To evaluate the concordance of a set of variables reported by patients and available in the electronic health record as part of a pragmatic clinical trial.

Design, Setting, and Participants

Data from ADAPTABLE (Aspirin Dosing: A Patient-Centric Trial Assessing Benefits and Long-term Effectiveness), a pragmatic clinical trial, were used in a concordance substudy of a comparative effectiveness research trial. The trial randomized 15 076 patients with existing atherosclerotic cardiovascular disease in a 1:1 ratio to low- or high-dose aspirin from April 2016 through June 30, 2019.

Main Outcomes and Measures

Concordance of data was evaluated from 4 domains (demographic characteristics, encounters, diagnoses, and procedures) present in 2 data sources: patient-reported data captured through an online portal and data from electronic sources (electronic health record data). Overall agreement, sensitivity, specificity, positive predictive value, negative predictive value, and κ statistics with 95% CIs were calculated using patient report as the criterion standard for demographic characteristics and the electronic health record as the criterion standard for clinical outcomes.

Results

Of 15 076 patients with complete information, the median age was 67.6 years (range, 21-99 years), and 68.7% were male. With the use of patient-reported data as the criterion standard, agreement (κ) was high for Black and White race and ethnicity but only moderate for current smoking status. Electronic health record data were highly specific (99.6%) but less sensitive (82.5%) for Hispanic ethnicity. Compared with electronic health record data, patient report of clinical end points had low sensitivity for myocardial infarction (33.0%), stroke (34.2%), and major bleeding (36.6%). Positive predictive value was similarly low for myocardial infarction (40.7%), stroke (38.8%), and major bleeding (21.9%). Coronary revascularization was the most concordant event by data source, with only moderate agreement (κ = 0.54) and positive predictive value. Agreement metrics varied by site for all demographic characteristics and several clinical events.

Conclusions and Relevance

In a concordance substudy of a large, pragmatic comparative effectiveness research trial, sensitivity and chance-corrected agreement of patient-reported data captured through an online portal for cardiovascular events were low to moderate. Findings suggest that additional work is needed to optimize integration of patient-reported health data into pragmatic research studies.

Trial Registration

ClinicalTrials.gov Identifier: NCT02697916.

Effectiveness of Standard vs Enhanced Self-measurement of Blood Pressure Paired With a Connected Smartphone Application: A Randomized Clinical Trial

Importance

Self-measured blood pressure (SMBP) with commercially available connected smartphone applications may help patients effectively use SMBP measurements.

Objective

To determine if enhanced SMBP paired with a connected smartphone application was superior to standard SMBP for blood pressure (BP) reduction or patient satisfaction.

Design, Setting, and Participants

This randomized clinical trial was conducted among 23 health systems participating in PCORnet, the National Patient-Centered Clinical Research Network, and included patients who reported having uncontrolled BP at their last clinic visit, a desire to lower their BP, and a smartphone. Enrollment and randomization occurred from August 3, 2019, to December 31, 2020, which was followed by 6 months of follow-up for each patient. Analysis commenced shortly thereafter.

Interventions

Eligible participants were randomly assigned to enhanced SMBP using a device that paired with a connected smartphone application (enhanced) or a standard device (standard). Participants received their device in the mail, along with web-based educational materials and phone-based support as needed. No clinician engagement was undertaken, and the study provided no special mechanisms for delivering measurements to clinicians for use in BP management.

Main Outcomes and Measures

Reduction in systolic BP, defined as the difference between clinic BP at baseline and the most recent clinic BP extracted from electronic health records at 6 months.

Results

Enrolled participants (1051 enhanced [50.0%] vs 1050 standard [50.0%]; 1191 women [56.7%]) were mostly middle-aged or older (mean [SD] age, 58 [13] years), nearly a third were Black or Hispanic (645 [31%]), and most were relatively comfortable using technology (mean [SD], 4.1 [1.1] of 5). The mean (SD) change in systolic BP from baseline to 6 months was -10.8 (18) mm Hg vs -10.6 (18) mm Hg (enhanced vs standard: adjusted difference, -0.19 mm Hg; 95% CI, -1.83 to 1.44; P = .81). Secondary outcomes were mostly null, except for documented attainment of BP control to lower than 140/<90 mm Hg, which occurred in 32% enhanced vs 29% standard groups (odds ratio, 1.15; 95% CI, 1.01-1.34). Most participants were very likely to recommend their SMBP device to a friend (70% vs 69%).

Conclusions and Relevance

This randomized clinical trial found that enhanced SMBP paired with a smartphone application is not superior to standard SMBP for BP reduction or patient satisfaction.

Trial Registration

ClinicalTrials.gov Identifier: NCT03796689.

Amyloid-β PET Scan Results Disclosure and Care-Partner Emotional Well-Being Over Time

Background: Diagnostic tests, such as amyloid-β positron emission tomography (PET) scans, can increase appropriate therapeutic management for the underlying causes of cognitive decline. To evaluate the full utility of this diagnostic tool, information is needed on whether results from amyloid-β PET scans influence care-partner outcomes. Objective: This study examines the extent to which previous disclosure of elevated amyloid (suggestive of Alzheimer’s disease (AD) etiology) versus not-elevated amyloid (not suggestive of AD etiology) is associated with changes in care-partner wellbeing. Methods: The study used data derived from a national longitudinal survey of Medicare beneficiaries (n = 921) with mild cognitive impairment (MCI) or dementia and their care-partners. Care-partner wellbeing outcomes included depressive symptoms (PHQ-8), subjective burden (4-item Zarit burden score), and a 3-item measure of loneliness. Change was measured between 4 (Time 1) and 18 (Time 2) months after receiving the scan results. Adjusted linear regression models regressed change (Time 2-Time 1) in each outcome on scan result. Results: Care-partners were primarily white, non-Hispanic, college-educated, and married to the care recipient. Elevated amyloid was not associated with statistically significant Time 1 differences in outcomes or with statistically significant changes in depressive symptoms 0.22 (–0.18, 0.61), subjective burden 0.36 (–0.01, 0.73), or loneliness 0.15 (–0.01, 0.32) for care-partners from one time point to another. Conclusion: Given advances in AD biomarker testing, future research in more diverse samples is needed to understand the influence of scan results on care-partner wellbeing across populations.

Prevalence, risk factors, and cardiovascular disease outcomes associated with persistent blood pressure control: The Jackson Heart Study

Background

Maintaining blood pressure (BP) control over time may contribute to lower risk for cardiovascular disease (CVD) among individuals who are taking antihypertensive medication.

Methods

The Jackson Heart Study (JHS) enrolled 5,306 African-American adults ≥21 years of age and was used to determine the proportion of African Americans that maintain persistent BP control, identify factors associated with persistent BP control, and determine the association of persistent BP control with CVD events. This analysis included 1,604 participants who were taking antihypertensive medication at Visit 1 and had BP data at Visits 1 (2000–2004), 2 (2005–2008), and 3 (2009–2013). Persistent BP control was defined as systolic BP <140 mm Hg and diastolic BP <90 mm Hg at all three visits. CVD events were assessed from Visit 3 through December 31, 2016. Hazard ratios (HR) for the association of persistent BP control with CVD outcomes were adjusted for age, sex, systolic BP, smoking, diabetes, and total and high-density lipoprotein cholesterol at Visit 3.

Results

At Visit 1, 1,226 of 1,604 participants (76.4%) with hypertension had controlled BP. Overall, 48.9% of participants taking antihypertensive medication at Visit 1 had persistent BP control. After multivariable adjustment for demographic, socioeconomic, clinical, behavioral, and psychosocial factors, and access-to-care, participants were more likely to have persistent BP control if they were <65 years of age, women, had family income ≥$25,000 at each visit, and visited a health professional in the year prior to each visit. The multivariable adjusted HR (95% confidence interval) comparing participants with versus without persistent BP control was 0.71 (0.46–1.10) for CVD, 0.68 (0.34–1.34) for coronary heart disease, 0.65 (0.27–1.52) for stroke, and 0.55 (0.33–0.90) for heart failure.

Conclusion

Less than half of JHS participants taking antihypertensive medication had persistent BP control, putting them at increased risk for heart failure.

Evaluating fitness-for-use of electronic health records in pragmatic clinical trials: reported practices and recommendations

OBJECTIVE

To empirically explore how pragmatic clinical trials (PCTs) that used real-world data (RWD) assessed study-specific fitness-for-use.

METHODS

We conducted interviews and surveys with PCT teams who used electronic health record (EHR) data to ascertain endpoints. The survey cataloged key concerns about RWD, activities used to assess data fitness-for-use, and related barriers encountered by study teams. Patterns and commonalities across trials were used to develop recommendations for study-specific fitness-for-use assessments.

RESULTS

Of 15 invited trial teams, 7 interviews were conducted. Of 31 invited trials, 15 responded to the survey. Most respondents had prior experience using RWD (93%). Major concerns about EHR data were data reliability, missingness or incompleteness of EHR elements, variation in data quality across study sites, and presence of implausible or incorrect values. Although many PCTs conducted fitness-for-use activities (eg, data quality assessments, 11/14, 79%), less than a quarter did so before choosing a data source. Fitness-for-use activities, findings, and resulting study design changes were not often publically documented. Overall costs and personnel costs were barriers to fitness-for-use assessments.

DISCUSSION

These results support three recommendations for PCTs that use EHR data for endpoint ascertainment. Trials should detail the rationale and plan for study-specific fitness-for-use activities, conduct study-specific fitness-for-use assessments early in the prestudy phase to inform study design changes before the trial begins, and share results of fitness-for-use assessments and description of relevant challenges and facilitators.

CONCLUSION

These recommendations can help researchers and end-users of real-world evidence improve characterization of RWD reliability and relevance in the PCT-specific context.

Depressive Symptoms and Incident Heart Failure in the Jackson Heart Study: Differential Risk Among Black Men and Women

Background Associations between depression, incident heart failure (HF), and mortality are well documented in predominately White samples. Yet, there are sparse data from racial minorities, including those who are women, and depression is underrecognized and undertreated in the Black population. Thus, we examined associations between baseline depressive symptoms, incident HF, and all-cause mortality across 10 years. Methods and Results We included Jackson Heart Study (JHS) participants with no history of HF at baseline (n=2651; 63.9% women; median age, 53 years). Cox proportional hazards models tested if the risk of incident HF or mortality differed by clinically significant depressive symptoms at baseline (Center for Epidemiological Studies-Depression scores ≥16 versus <16). Models were conducted in the full sample and by sex, with hierarchical adjustment for demographics, HF risk factors, and lifestyle factors. Overall, 538 adults (20.3%) reported high depressive symptoms (71.0% were women), and there were 181 cases of HF (cumulative incidence, 0.06%). In the unadjusted model, individuals with high depressive symptoms had a 43% greater risk of HF (P=0.035). The association remained with demographic and HF risk factors but was attenuated by lifestyle factors. All-cause mortality was similar regardless of depressive symptoms. By sex, the unadjusted association between depressive symptoms and HF remained for women only (P=0.039). The fully adjusted model showed a 53% greater risk of HF for women with high depressive symptoms (P=0.043). Conclusions Among Black adults, there were sex-specific associations between depressive symptoms and incident HF, with greater risk among women. Sex-specific management of depression may be needed to improve cardiovascular outcomes.

Use of Lipid-, Blood Pressure-, and Glucose-Lowering Pharmacotherapy in Patients With Type 2 Diabetes and Atherosclerotic Cardiovascular Disease

IMPORTANCE

Based on contemporary estimates in the US, evidence-based therapies for cardiovascular risk reduction are generally underused among patients with type 2 diabetes and atherosclerotic cardiovascular disease (ASCVD).

OBJECTIVE

To determine the use of evidence-based cardiovascular preventive therapies in a broad US population with diabetes and ASCVD.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter cohort study used health system-level aggregated data within the National Patient-Centered Clinical Research Network, including 12 health systems. Participants included patients with diabetes and established ASCVD (ie, coronary artery disease, cerebrovascular disease, and peripheral artery disease) between January 1 and December 31, 2018. Data were analyzed from September 2020 until January 2021.

EXPOSURES

One or more health care encounters in 2018.

MAIN OUTCOMES AND MEASURES

Patient characteristics by prescription of any of the following key evidence-based therapies: high-intensity statin, angiotensin-converting enzyme inhibitor (ACEI) or angiotensin-receptor blocker (ARB) and sodium glucose cotransporter-2 inhibitors (SGLT2I) or glucagon-like peptide-1 receptor agonist (GLP-1RA).

RESULTS

The overall cohort included 324 706 patients, with a mean (SD) age of 68.1 (12.2) years and 144 169 (44.4%) women and 180 537 (55.6%) men. A total of 59 124 patients (18.2% ) were Black, and 41 470 patients (12.8%) were Latinx. Among 205 885 patients with specialized visit data from the prior year, 17 971 patients (8.7%) visited an endocrinologist, 54 330 patients (26.4%) visited a cardiologist, and 154 078 patients (74.8%) visited a primary care physician. Overall, 190 277 patients (58.6%) were prescribed a statin, but only 88 426 patients (26.8%) were prescribed a high-intensity statin; 147 762 patients (45.5%) were prescribed an ACEI or ARB, 12 724 patients (3.9%) were prescribed a GLP-1RA, and 8989 patients (2.8%) were prescribed an SGLT2I. Overall, 14 918 patients (4.6%) were prescribed all 3 classes of therapies, and 138 173 patients (42.6%) were prescribed none. Patients who were prescribed a high-intensity statin were more likely to be men (59.9% [95% CI, 59.6%-60.3%] of patients vs 55.6% [95% CI, 55.4%-55.8%] of patients), have coronary atherosclerotic disease (79.9% [95% CI, 79.7%-80.2%] of patients vs 73.0% [95% CI, 72.8%-73.3%] of patients) and more likely to have seen a cardiologist (40.0% [95% CI, 39.6%-40.4%] of patients vs 26.4% [95% CI, 26.2%-26.6%] of patients).

CONCLUSIONS AND RELEVANCE

In this large cohort of US patients with diabetes and ASCVD, fewer than 1 in 20 patients were prescribed all 3 evidence-based therapies, defined as a high-intensity statin, either an ACEI or ARB, and either an SGLT2I and/or a GLP-1RA. These findings suggest that multifaceted interventions are needed to overcome barriers to the implementation of evidence-based therapies and facilitate their optimal use.

The PCORnet Blood Pressure Control Laboratory: A Platform for Surveillance and Efficient Trials

BACKGROUND

Uncontrolled blood pressure (BP) is a leading preventable cause of death that remains common in the US population despite the availability of effective medications. New technology and program innovation has high potential to improve BP but may be expensive and burdensome for patients, clinicians, health systems, and payers and may not produce desired results or reduce existing disparities in BP control.

METHODS AND RESULTS

The PCORnet Blood Pressure Control Laboratory is a platform designed to enable national surveillance and facilitate quality improvement and comparative effectiveness research. The platform uses PCORnet, the National Patient-Centered Clinical Research Network, for engagement of health systems and collection of electronic health record data, and the Eureka Research Platform for eConsent and collection of patient-reported outcomes and mHealth data from wearable devices and smartphones. Three demonstration projects are underway: BP track will conduct national surveillance of BP control and related clinical processes by measuring theory-derived pragmatic BP control metrics using electronic health record data, with a focus on tracking disparities over time; BP MAP will conduct a cluster-randomized trial comparing effectiveness of 2 versions of a BP control quality improvement program; BP Home will conduct an individual patient-level randomized trial comparing effectiveness of smartphone-linked versus standard home BP monitoring. Thus far, BP Track has collected electronic health record data from over 826 000 eligible patients with hypertension who completed ≈3.1 million ambulatory visits. Preliminary results demonstrate substantial room for improvement in BP control (<140/90 mm Hg), which was 58% overall, and in the clinical processes relevant for BP control. For example, only 12% of patients with hypertension with a high BP measurement during an ambulatory visit received an order for a new antihypertensive medication.

CONCLUSIONS

The PCORnet Blood Pressure Control Laboratory is designed to be a reusable platform for efficient surveillance and comparative effectiveness research; results from demonstration projects are forthcoming.

Abstract WMP85: Clinical Effectiveness of Direct Oral Anticoagulants (DOACs) vs. Warfarin in Older Ischemic Stroke Patients With Atrial Fibrillation: Findings From Patient-Centered Research Into Outcomes Stroke Patients Prefer and Effectiveness Research (PROSPER) Study

Introduction: Direct oral anticoagulants (DOACs) are increasingly used as alternatives to warfarin for secondary prevention in ischemic stroke patients with atrial fibrillation. Despite demonstrated efficacy in clinical trials, there are few real-world experiences of DOACs vs. warfarin in community practice.

Methods: We analyzed ischemic stroke survivors with atrial fibrillation discharged from the Get With The Guidelines Stroke hospitals between 2011-2014 and linked to Medicare claims for longitudinal outcomes through 2015. A propensity score overlap weighting method was used to compare DOACs vs. warfarin. The primary outcomes were major adverse cardiovascular events (MACE) and home time, a patient-centered outcome reflecting desire of “being alive at home, without recurrent stroke, or being hospitalized for complications.”

Results: Among 11,662 stroke survivors (median age 80), 4,041 (34.7%) were discharged on DOACs (dabigatran, rivaroxaban, or apixaban) and 7,621 on warfarin. Except for NIHSS (median 4 [IQR 1-9] vs. 5 [2-11]), baseline demographics, medical history, and clinical characteristics were similar between two cohorts. Compared with warfarin, patients discharged on DOACs were less likely to experience MACE (33.95% vs. 40.36% per year, adjusted hazard ratio 0.89, 99% CI 0.83-0.96) and had more days at home (mean 287 vs. 263 days during the first year post discharge, adjusted difference 15.6 days, 99% CI 9.0-22.1) ( Table ). Additionally, there were fewer deaths, all-cause readmissions, cardiovascular readmissions, hemorrhagic strokes, and bleeding hospitalizations in DOAC-treated patients, although no significant differences in fatal bleeding, ischemic stroke readmission, systemic embolism, pneumonia, or sepsis (two negative outcome controls) between the two cohorts.

Conclusions: In ischemic stroke survivors with atrial fibrillation, DOACs were associated with improved long-term clinical outcomes compared with warfarin.

Abstract 17: Association Between Pre-stroke Depression and Patient Reported Outcomes After Acute Ischemic Stroke

Background: Post-stroke depression has been shown to have a negative impact on patients’ quality of life but data regarding the relationship between pre-stroke depression and post-stroke outcomes are lacking.

Methods: Patient reported outcome measures (PROMS) were prospectively collected (January 2014 – December 2014) as a part of PROSPER, a PCORI-funded study designed by researchers and stroke survivors to evaluate the effectiveness of therapies post-stroke. PROMS evaluated in the study included modified Rankin Scale (mRS) assessed at discharge, 3 months and 6 months post-discharge. EuroQual-5D-3L (EQ-5D-3L), EuroQual Visual Analog Scale (EQ-VAS), Patient Health Questionnaire-2 (PHQ-2), Stroke Impact Scale-16 (SIS-16), and Fatigue Severity Scale (FSS) were assessed at 3 months and 6 months post-discharge. Pre-stroke depression was identified from patient medical history. Validated dichotomized endpoints were used to create regression models to examine association of pre-stroke depression with PROMS.

Results: Of 1,617 enrolled patients at 60 hospitals, 185 (11.4%) had pre-stroke depression. Patients with documented pre-stroke depression were more likely to be white, female and have a higher prevalence of cardiovascular risk factors than those without pre-stroke depression. While both cohorts had similar stroke severity and functional status at discharge, patients with pre-stroke depression had significantly worse PROMS at 3 months and 6 months post-discharge. Pre-stroke depression was associated with 56% higher odds of functional decline between 3 months and 6 months post-discharge with greater negative impact of stroke on patient’s health and life, and with increased likelihood of reporting severe fatigue during stroke recovery (Table 1).

Conclusions: Pre-stroke depression is associated with worse patient reported outcomes and greater odds of functional decline after ischemic stroke discharge. Strategies to more effectively manage comorbid depression and improve outcomes in these patients are needed.

Abstract TMP39: Patterns of Discharge Antidepressant Therapy Use After Acute Ischemic Stroke: Insights From the Prosper Study

Background: Antidepressant (AD) therapy has been shown to improve post-stroke depressive symptoms, yet few data are available on characteristics associated with treatment at the time of discharge after ischemic stroke.

Methods: PROSPER is a PCORI-funded study designed by researchers and stroke survivors to evaluate the effectiveness of therapies post-stroke. We used information from ischemic stroke patients discharged from April 2014 - December 2014 in the American Heart Association’s Get With The Guidelines (GWTG)-Stroke registry who were linked to Centers for Medicare and Medicaid Services (CMS) data to evaluate antidepressant medication use following hospitalization for ischemic stroke.

Results: Of 29,177 eligible patients from 1,023 hospitals, n=7,593 (26.0%) were prescribed AD at hospital discharge. The majority of discharge AD prescriptions were for an SSRI (70.6%) and in patients with history of depression and on AD prior to admission. Patients discharged on an AD were more likely to be female, of white race, and to have a prior history of cardiovascular diseases (Table). Discharge AD prescription was more common at teaching hospitals, hospitals with larger bed size and higher annual volume of ischemic stroke admissions. Amongst the patients who were not on AD prior to admission (22,437), only 8.1% were discharged on AD. Patients discharged on AD amongst AD naïve population were more likely to be female, of white race, had prior history of depression, had higher initial NIHSS and more likely to be discharged to a facility.

Conclusions: Among CMS linked patients, antidepressant prescription after ischemic stroke is low and varies by key patient and hospital level characteristics. Future research examining the association between discharge AD use and patient reported outcomes after stroke is needed.

Abstract 057: Understanding of Treatment Strategies Among Patients Newly Diagnosed With Atrial Fibrillation: Findings From SATELITTE

Introduction: Patient understanding of available therapies for atrial fibrillation (AF) is foundational to shared medical decision making and long term medication adherence. Yet, there is a paucity of data regarding the extent to which patients newly diagnosed with AF in routine community practice understand their options.

Hypotheses: 1) Understanding of warfarin, novel oral anticoagulants (NOAC), rhythm control therapy, cardioversion and radio frequency ablation changes little from baseline to 6 months and 2) treatment rates at 6 months are associated with patient understanding of therapies at baseline.

Methods: We analyzed survey data from SATELLITE, a substudy of new-onset AF patients enrolled at 56 US sites participating in the ORBIT-AF registry. Patients were surveyed at the baseline and 6 month follow up clinic visit using Likert scales. Agreement between time points was assessed with the McNemar test, and the relationship between understanding and treatment was assessed only for the subset not on treatment at baseline.

Results: Of 1000 patients enrolled in SATELLITE, 506 had 6-month survey data (data collection is continuing). Among these, the median age was 69.0 years (IQR 63.0 - 76.0) and 93.7% (474 of 506) were white. There was evidence of improvement in the self-reported understanding of warfarin and NOACs from baseline to 6 months, but not for rhythm control, ablation or cardioversion. The proportion reporting high understanding improved significantly for warfarin (p<.0001) and NOACs (p<.0001) from 47% (223 of 474) and 51% (245 of 481) at baseline to 60% (284 of 474) and 69% (332 of 481) at 6 months respectively (Figure 1). Patients with high understanding of the benefits of ablation (p=0.0005) and options for ablation (p=0.0093) at baseline were more likely to have this therapy at the 6 month follow up (N=590), but improved understanding was not associated with increased use of warfarin/NOACs (N=83) or rhythm control (N=444).

Conclusions: Patients with new-onset AF had improved self-reported understanding of some treatment options over the first 6-months from diagnosis; however, factors other than patient understanding may influence AF treatments received at 6 months. Patient understanding of AF treatments remains suboptimal at 6 months, and our results suggest a need for ongoing patient education.

Hospital Variation in Home-Time After Acute Ischemic Stroke

Background and Purpose—

Stroke survivors identify home-time as a high-priority outcome; there are limited data on factors influencing home-time and home-time variability among discharging hospitals.

Methods—

We ascertained home-time (ie, time alive out of a hospital, inpatient rehabilitation facility, or skilled nursing facility) at 90 days and 1-year post discharge by linking data from Get With The Guidelines-Stroke Registry patients (≥65 years) to Medicare claims. Using generalized linear mixed models, we estimated adjusted mean home-time for each hospital. Using linear regression, we examined associations between hospital characteristics and risk-adjusted home-time.

Results—

We linked 156 887 patients with ischemic stroke at 989 hospitals to Medicare claims (2007–2011). Hospital mean home-time varied with an overall unadjusted median of 59.5 days over the first 90 days and 270.2 days over the first year. Hospital factors associated with more home-time over 90 days included higher annual stroke admission volume (number of ischemic stroke admissions per year); South, West, or Midwest geographic regions (versus Northeast); and rural location; 1-year patterns were similar. Lowest home-time quartile patients (versus highest) were more likely to be older, black, women, and have more comorbidities and severe strokes. Home-time variation decreased after risk adjustment (interquartile range, 57.4–61.4 days over 90 days; 266.3–274.2 days over 1 year). In adjusted analyses, increasing annual stroke volume and rural location were associated with significantly more home-time.

Conclusions—

In older ischemic stroke survivors, home-time post discharge varies by hospital annual stroke volume, severity of case-mix, and region. In adjusted analyses, annual ischemic stroke admission volume and rural location were associated with more home-time post stroke.

Abstract 10: Pre-stroke Antithrombotic Therapy and Stroke Severity in Acute Ischemic Stroke Patients with Atrial Fibrillation

Background: Antithrombotic therapies are known to prevent thromboembolic events and stroke for patients with atrial fibrillation (AF). Despite this, it is unclear in contemporary practice what percentage of AF patients presenting with acute ischemic stroke (AIS) receive antithrombotic therapy prior to stroke and how pre-stroke antithrombotic therapy affects stroke severity, particularly in the era of non-vitamin K antagonist oral anticoagulants (NOACs).

Methods: We analyzed data from 1625 Get With The Guidelines-Stroke hospitals between October 2012 and March 2015. Multivariable logistic regression was performed to evaluate the association between antithrombotic therapy and stroke severity according to NIHSS.

Results: Of 103,327AIS patients with pre-stroke AF, 28,583 (28%) were not on any home antithrombotics prior to their stroke, and another 30,149 (29%) were receiving aspirin alone; followed by warfarin alone (18,532, 18%) with only a quarter (4705/18,532) in the therapeutic range, aspirin and warfarin (7130, 7%), and NOACs alone (5803, 6%) ( Figure ). Even among patients with a CHA2DS2-VASc score≥2, only one third of them (34,145/99,807) were receiving some form of oral anticoagulant. Stroke severity was associated with home antithrombotic use ( Figure ). Compared with those receiving aspirin alone, warfarin with INR≥2 (adjusted odds ratio [aOR], 0.72, 95% CI 0.66-0.79), aspirin and warfarin (aOR 0.83, 95% CI 0.77-0.90), NOACs alone (aOR 0.83, 95% CI 0.77-0.91), NOACs with aspirin or clopidogrel (aOR 0.69, 95% 0.60-0.79), aspirin and clopidogrel (aOR 0.90, 95% CI 0.83-0.99), or triple antithrombotic therapy (aOR 0.64, 95% 0.49-0.84) were associated with a lower likelihood of severe stroke (NIHSS≥16). In contrast, patients subtherapeutic (INR<2 or INR missing) on warfarin (aOR 1.07, 95% 1.01-1.13) and those not receiving any antithrombotic treatment (aOR 1.10, 95% 1.05-1.15) were more likely to present with more severe stroke.

Conclusions: A majority of AF patients presenting with AIS are not on guideline recommended anticoagulation or are not therapeutic on their anticoagulation. Even when strokes occurred on therapeutic warfarin or a NOAC, the strokes were less severe. These findings highlight the huge opportunities to further improve proper use of oral anticoagulants in eligible AF patients.

Abstract 130: Clinically Important Difference in the Atrial Fibrillation Effect on QualiTy-of-Life (AFEQT) Score: Results from the ORBIT-AF Registry

Background: The Atrial Fibrillation Effect on QualiTy-of-Life (AFEQT) survey has recently been validated to measure the impact of atrial fibrillation on patients’ quality of life, but a clinically important difference (CID) in AFEQT score has not been defined. Knowing the CID is needed to interpret the meaningfulness of differences between treatments in clinical trials; or patient populations for quality assessment.

Objectives: To calculate CID values in AFEQT in the ORBIT registry.

Methods: ORBIT-AF is a US-based outpatient AF registry that measured disease-specific QoL with the AFEQT tool (score range= 0 (worst) to 100) at baseline and at 1 year follow-up. Two anchor-based methods were used to relate changes in AFEQT to clinically important differences in the more established European Heart Rhythm Association (EHRA) measure of functional status. Ranging from 1 (no symptoms) to 4 (disabling), a change of 1 EHRA class was defined as an important change in the anchor. Both the mean change and receiver operating characteristics (ROC) methods were then used to identify CIDs in AFEQT at 1 year follow-up. This was done for both improvement and worsening on the anchor. The mean change method defines a CID as the mean change in AFEQT score among patients with a 1 EHRA class change. The ROC method identifies a CID as the point on the ROC curve that best discriminates patients who experienced an important change in the anchor (≥ 1 EHRA class change) from those who experienced no change.

Results: AFEQT was assessed in 2008 AF patients at baseline and 1347 patients at 1 year from 99 US sites participating in ORBIT-AF. CIDs and 95% confidence intervals (CI) corresponding to an improvement in EHRA for the mean change method were 5.4 (3.6, 7.2) AFEQT points and 1.9 (0.4, 9.3) AFEQT points for the ROC method. CIDs corresponding to worsening in EHRA for the mean change method were -4.2 (-6.9,-1.5) AFEQT points and -7.4 (-13.9,-4.6) AFEQT points for the ROC method.

Conclusions: Changes in AFEQT as small as 2 points may be clinically relevant, although CIDs vary depending on the method of calculation. The variability suggests identifying a single universal CID to assess improvement in quality of life in AF patients may not be ideal and improvement may relate to the nature of a patient’s symptoms and their baseline level of activity.

Assessment of Home-Time After Acute Ischemic Stroke in Medicare Beneficiaries

Background and Purpose—

Stroke survivors have identified home-time as a meaningful outcome. We evaluated home-time as a patient-centered outcome in Medicare beneficiaries with ischemic stroke in comparison with modified Rankin Scale (mRS) score at 90 days and at 1 year post event.

Methods—

Patients enrolled in Get With The Guidelines-Stroke (GWTG-Stroke) and Adherence Evaluation After Ischemic Stroke-Longitudinal (AVAIL) registries were linked to Medicare claims to ascertain home-time, defined as time spent alive and out of a hospital, inpatient rehabilitation, or skilled nursing facilities, at 90 days and at 1 year after admission. The correlation of home-time with mRS at 90 days and at 1 year was evaluated by Pearson correlation coefficients, and the ability of home-time to discriminate mRS (0–2) was assessed by c -index.

Results—

There were 815 patients with ischemic stroke (age median, 76 years [interquartile range {IQR}, 70–82]; 46% women; National Institutes of Health Stroke Scale median, 4 [IQR, 2–7]) from 88 hospitals. The 90-day and 1-year median home-times were 79 (IQR, 52–86) days and 349 (IQR, 303–360) days and median mRS were 2 (IQR, 1–4) and 2 (IQR, 1–4). Greater home-time within 90 days was significantly correlated with lower 90-day mRS (Pearson correlation coefficient, −0.731; P <0.0001) and showed strong ability to discriminate functional independence with mRS 0 to 2 ( c -index, 0.837). Similar findings were observed at 1 year.

Conclusions—

In a population of older patients with ischemic stroke, home-time was readily available from administrative data and associated with mRS at 90 days and 1 year. Home-time represents a novel, easily measured, patient-centered, outcome measure for an episode of stroke care.

Abstract 14: Clinical Characteristics and Treatment Patterns of Medicaid Patients with Atrial Fibrillation: Insights From the ORBIT-AF I Registry

Background: Little is known about whether insurance status affects the presentation and treatment of patients with atrial fibrillation (AF).

Methods: We used data from the ORBIT-AF Registry (2010 - 2011), a national, large outpatient registry, to evaluate clinical characteristics and oral anticoagulation (OAC) use. We examined differences in comorbidities and receipt of OAC among patients enrolled in the Medicaid program at baseline compared with those not enrolled in Medicaid. After restricting to patients who were taking OAC, we compared receipt of novel oral anticoagulants (dabigatran or rivaroxaban) versus warfarin by Medicaid status during 2 years of followup. We used logistic regression models adjusting for demographic and clinical covariates to evaluate baseline OAC receipt by Medicaid status.

Results: Of 10,133 patients, N=470 (4.6%) were classified as having Medicaid insurance. Compared with those with other insurance, Medicaid patients were younger (70.0 years; IQR=61.0 - 79.0 vs. 75.0 years; IQR=67.0 - 82.0), more likely to be female (53.0% vs. 41.8%), and less likely to be white (58.7% vs. 90.7%; all p<0.001). Medicaid patients had higher rates of smoking, prior stroke/TIA, diabetes, hypertension, and HF. Medicaid patients were less likely to be taking OAC at baseline, a difference that was particularly pronounced for high stroke risk patients (CHADS2>=2, p<0.001; Table). Among those on anticoagulation, Medicaid patients were less likely to receive NOAC over 2 years of followup. In adjusted analyses, Medicaid patients were less likely to receive OAC at baseline, but this difference was not statistically significant (HR = 0.82; 95% CI = 0.61, 1.09). Among untreated patients with CHADS2>=2, Medicaid patients were more likely than patients with other insurance to have “unable to adhere/monitor” listed as a contraindication to OAC (p<0.001).

Conclusions: In a contemporary, community-based AF cohort, Medicaid patients had a greater comorbidity burden and higher stroke risk, yet were less likely to receive OAC compared with those with other forms of insurance.

Abstract W MP106: Clinical Effectiveness of Anticoagulation with Warfarin among Ischemic Stroke Patients with Atrial Fibrillation: Findings from the Patient-Centered Research into Outcomes Stroke Patients Prefer and Effectiveness Research (PROSPER) Study

Background: Oral anticoagulation is recommended for ischemic stroke patients with atrial fibrillation, based on clinical trials done in selected populations. However, little is known about whether the clinical benefit of warfarin is preserved outside the clinical trial setting, especially in older patients with ischemic stroke.

Methods: PROSPER, a PCORI-funded research program designed by stroke survivors and stakeholders, used American Heart Association Get With The Guidelines (GWTG)-Stroke data linked to Medicare claims to evaluate the association between warfarin treatment at discharge and long-term outcomes among ischemic stroke survivors with atrial fibrillation (AF) and no contraindication to or prior anticoagulation therapy. The primary outcome prioritized by patients was home-time (defined as days spent alive and not in inpatient post-acute care facility) within 2-year follow-up after discharge.

Results: Of 12,552 ischemic stroke patients with AF admitted from 2009-2011, 11,039 (88%) received warfarin treatment at discharge. Compared with those not receiving any anticoagulation, warfarin-treated patients were slightly younger (mean 80 vs. 83, p<0.001), less likely to have a history of prior stroke or coronary artery disease, but had similar stroke severity as measured by NIHSS (median 5 [IQR 2-12] vs. 6 [2-13], p=0.09). After adjustment for all observed baseline characteristics using propensity score inverse probability weighting method, patients discharged on warfarin therapy had 45 more days of home-time during 2-year follow-up than those not receiving any oral anticoagulant (513 vs. 468 days, p<0.001). Warfarin use was also associated with a lower risk of all-cause mortality, cardiovascular readmission or death, and ischemic stroke (Table).

Conclusions: Among ischemic stroke patients with atrial fibrillation, warfarin therapy was associated with improved long-term outcomes.

Reducing the burden of disease and death from familial hypercholesterolemia: a call to action

Familial hypercholesterolemia (FH) is a genetic disease characterized by substantial elevations of low-density lipoprotein cholesterol, unrelated to diet or lifestyle. Untreated FH patients have 20 times the risk of developing coronary artery disease, compared with the general population. Estimates indicate that as many as 1 in 500 people of all ethnicities and 1 in 250 people of Northern European descent may have FH; nevertheless, the condition remains largely undiagnosed. In the United States alone, perhaps as little as 1% of FH patients have been diagnosed. Consequently, there are potentially millions of children and adults worldwide who are unaware that they have a life-threatening condition. In countries like the Netherlands, the United Kingdom, and Spain, cascade screening programs have led to dramatic improvements in FH case identification. Given that there are currently no systematic approaches in the United States to identify FH patients or affected relatives, the patient-centric nonprofit FH Foundation convened a national FH Summit in 2013, where participants issued a "call to action" to health care providers, professional organizations, public health programs, patient advocacy groups, and FH experts, in order to bring greater attention to this potentially deadly, but (with proper diagnosis) eminently treatable, condition.

Rationale and design of the familial hypercholesterolemia foundation CAscade SCreening for Awareness and DEtection of Familial Hypercholesterolemia registry

BACKGROUND

Familial hypercholesterolemia (FH) is a hereditary condition caused by various genetic mutations that lead to significantly elevated low-density lipoprotein cholesterol levels and resulting in a 20-fold increased lifetime risk for premature cardiovascular disease. Although its prevalence in the United States is 1 in 300 to 500 individuals, <10% of FH patients are formally diagnosed, and many are not appropriately treated. Contemporary data are needed to more fully characterize FH disease prevalence, treatment strategies, and patient experiences in the United States.

DESIGN

The Familial Hypercholesterolemia Foundation (a patient-led nonprofit organization) has established the CAscade SCreening for Awareness and DEtection of Familial Hypercholesterolemia (CASCADE FH) Registry as a national, multicenter initiative to identify US FH patients, track their treatment, and clinical and patient-reported outcomes over time. The CASCADE FH will use multiple enrollment strategies to maximize identification of FH patients. Electronic health record screening of health care systems will provide an efficient mechanism to identify undiagnosed patients. A group of specialized lipid clinics will enter baseline and annual follow-up data on demographics, laboratory values, treatment, and clinical events. Patients meeting prespecified low-density lipoprotein or total cholesterol criteria suspicious for FH will have the opportunity to self-enroll in an online patient portal with information collected directly from patients semiannually. Registry patients will be provided information on cascade screening and will complete an online pedigree to assist with notification of family members.

SUMMARY

The Familial Hypercholesterolemia Foundation CASCADE FH Registry represents a novel research paradigm to address gaps in knowledge and barriers to comprehensive FH screening, identification, and treatment.

Abstract 10: Contraindications to Oral Anticoagulation in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF)

Background. Oral anticoagulation therapy (OAC) reduces the risk of thromboembolic events associated with atrial fibrillation (AF), yet a substantial proportion of patients with AF are not prescribed OAC. The frequencies of and factors associated with contraindications to OAC therapy in clinical practice are not well-described.

Methods. We used data from the ORBIT-AF study, a national, prospective, outpatient registry of incident and prevalent AF. OAC contraindications were uniformly collected at study enrollment by site personnel. Patient and provider characteristics were compared between participants with documented OAC contraindications at baseline and those without OAC contraindications.

Results. From June 2010 to August 2011, 10124 patients ≥18 years old with electrocardiographically documented AF were enrolled at 176 practices. Of these, 1409 (13.9%) had OAC contraindications documented at the baseline visit: prior bleed (26.2%), patient refusal/preference (26.0%), high bleeding risk (22.6%), frequent falls/frailty (16.6%), other (11.9%), need for dual antiplatelet therapy (9.8%), unable to adhere/monitor warfarin (5.7%), comorbid illness (5.0%), prior intracranial hemorrhage (4.7%), allergy (2.3%), occupational risk (0.8%), and pregnancy (0.2%). Compared to patients without contraindications, those with contraindications had higher stroke risk (CHADS2>2) and were older, more likely to be female, more likely to be seen by a cardiologist and less likely to be seen by an electrophysiologist (Table 1). Among those patients with reported contraindications, 28.4% were taking warfarin.

Conclusions. Contraindications to OAC therapy among AF patients are common and often due to high bleeding risk. Furthermore, many patients with reported contraindications are taking warfarin, suggesting that many contraindications to warfarin therapy are minor, relative, or temporary.

Abstract 79: Reasons for Warfarin Discontinuation in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF)

Background. Warfarin reduces the risk of thromboembolic events associated with atrial fibrillation (AF), but therapeutic persistence is suboptimal. Few studies have investigated the reasons for warfarin discontinuation in community practice.

Methods. We used data from ORBIT-AF, the nation’s largest AF database, to examine patterns of warfarin discontinuation over a one-year period. Patients transitioned to non-warfarin oral anticoagulation therapy were excluded. We compared patient and provider characteristics between individuals who discontinued warfarin and those who persisted.

Results. From June 2010 to August 2011, 10,126 AF patients 18 years or older were enrolled at 176 ORBIT-AF practices. Of these, 6,559 (64.8%) were taking warfarin at baseline and have follow-up data; 514 (7.8%) of these switched to dabigatran and were excluded from the analysis. Additionally, two patients without follow-up warfarin data were excluded from the analysis. Over one year, 587 patients (9.7%) discontinued warfarin therapy. Compared to persistent users, patients who discontinued warfarin were younger, less likely to be white, had lower stroke risk (CHADS 2 <2), were more likely to follow a rhythm control strategy, and were less likely to be managed in an anticoagulation clinic (Table 1). The most commonly reported reasons for warfarin discontinuation were physician preference (31.0%), other (18.7%), patient refusal/preference (13.6%), bleeding event (13.3%), frequent falls/frailty (7.3%), high bleeding risk (6.6%), and patient inability to adhere to/monitor therapy (2.9%).

Conclusions. Discontinuation of warfarin is common among patients with atrial fibrillation. Patient and physician preference are major contributors to persistence on warfarin therapy.