Atrial fibrillation and stroke prevention with warfarin in the long-term care setting
Atrial fibrillation and stroke prevention with warfarin in the long-term care setting
复制标题
DOI：
10.1001/archinte.157.9.978
复制
发表时间：
1997-05-12
影响因子：
--
通讯作者：
Avorn, J
中科院分区：
文献类型：
--
作者：
Gurwitz, JH;Monette, J;Avorn, J
背景：虽然华法林钠疗法预防心房颤动(房颤)患者卒中的益处已经有了广泛的文献记载，但将临床试验结果推广到大多数房颤患者，特别是那些居住在长期护理环境中的老年人，仍然是具有挑战性的。目的：确定住院老年人群中房颤的患病率和接受华法林抗凝治疗的比例；确定与使用华法林相关的住院老年房颤患者的临床和功能特征；以及评估住院老年房颤患者华法林治疗的处方和监测的质量。分布在新英格兰、魁北克和安大略省。测定接受华法林治疗的房颤患者的比例。临床和功能特征与华法林使用之间的关联通过粗略和多变量调整分析进行了检验。对于在病历提取日期前12个月内至少接受华法林治疗2周的研究对象，我们根据所有国际标准化比率或凝血酶原时间比率值来评估华法林处方的质量。结果：5500名长期护理居民中有413人(7.5%)的心电图显示AP，其中32%的患者正在接受华法林治疗。在这种情况下，只有中风病史与华法林的使用呈正相关。被诊断为痴呆症的患者和年龄最大的人群(大于或等于85岁)接受华法林治疗的可能性较小。华法林通常被开给有出血史、严重合并症和功能损害、跌倒史或伴随加强药物治疗的患者。患者维持在推荐治疗范围的60%以上或以下。结论：房颤在长期护理机构的患者中很常见，但华法林对其的处理具有很高的变异性，需要对这些患者使用华法林预防卒中的决策采取更系统的方法。在接受华法林治疗的患者中，抗凝护理的质量需要提高。
Background: While the benefits of warfarin sodium therapy for stroke prevention in patients with atrial fibrillation (AF) have been extensively documented, generalizing clinical trial results to the majority of elderly persons with AF, especially to those who reside in the long-term care setting, remains challenging.Objectives: To determine the prevalence of AF in the institutionalized elderly population and the proportion receiving anticoagulation therapy with warfarin; to identify the clinical and functional characteristics of institutionalized elderly persons with AF that are associated with the use of warfarin; and to assess the quality of prescribing and monitoring of warfarin therapy in institutionalized elderly persons with AF.Methods: This study involved 30 long-term care facilities (total No. of beds, 6437) located in New England, Quebec, and Ontario. The proportion of patients with AF who were receiving treatment with warfarin was determined. The association between clinical and functional characteristics and the use of warfarin was examined with crude and multivariable-adjusted analyses. For study subjects with at least 2 weeks of warfarin therapy during the 12-month period preceding the date of medical record abstraction, we assessed the quality of warfarin prescribing based on all international normalized ratio or prothrombin time ratio values during this period.Results: An electrocardiogram indicating AP was present in the records of 413 of 5500 long-term care residents (7.5%), 32% of such patients were being treated with warfarin. Only a history of stroke was found to be positively associated with the use of warfarin in this setting. Patients with a diagnosis of dementia and those in the oldest age group (greater than or equal to 85 years) were less likely to receive warfarin therapy. Warfarin was commonly prescribed to patients with a history of bleeding, substantial comorbidity and functional impairment, a history of falls, or concomitant potentiating drug therapy. Patients were maintained above or below the recommended therapeutic range 60% of the lime.Conclusions: Atrial fibrillation is common in patients residing in long-term care facilities, but its management with warfarin is highly variable, A more systematic approach to decision making regarding the use of warfarin for stroke prevention in these patients is required. Among patients receiving warfarin, the quality of anticoagulation care warrants improvement.