Quality of anticoagulation with warfarin in patients with nonvalvular atrial fibrillation in the community setting Seol Young Han, MD, a Sebastian T. Palmeri, MD, b Samuel H. Broderick, MS, c Vic Hasselblad, PhD, c Dave Rendall, PA-C, c Scott Stevens, MD, d Alan Tenaglia, MD, e Eric Velazquez, MD, c David Whellan, MD, f Galen Wagner, MD, c John F. Heitner, MD a, ⁎ a New York Methodist Hospital, Brooklyn, NY, USA b UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ, USA c Duke University Medical Center, Duke Clinical Research Institute, Durham, NC, USA d Intermountain Medical Center, Salt Lake City, UT, USA e Scottsdale Cardiovascular Center, AZ, USA f Thomas Jefferson University, Jefferson Heart Institute Received 6 June 2012 Abstract Background: The benefit of oral anticoagulation therapy with warfarin for stroke prevention in atrial fibrillation (AF) is directly dependent on the quality of anticoagulation (QoA), which in the US is provided predominantly in the community setting. With the emergence of new oral anticoagulation agents, the current QoA needs to be assessed. Objectives: The purpose of our study is to define the QoA with warfarin in patients with nonvalvular AF who are managed exclusively in community practices, and to compare the quality in the community setting with the quality demonstrated in the recent large randomized control trials. In addition, this study will assess the differences in the QoA based on cardiology vs primary care practices. Methods: This is a retrospective, observational, multi-center study of 392 patients with AF in the community who were initiated on anticoagulation with warfarin for stroke prevention. International Normalized Ratio (INR) values were collected over a one-year period and the QoA was expressed as time in therapeutic range (TTR) calculated by the linear interpolation method. Results: One hundred patients from cardiology practices and 292 patients from primary care were studied. During the one-year period, the overall mean TTR was 56.7%. The TTR in the primary care vs cardiology practices was 55.3% vs. 60.8% (p=0.02). Both practices had similar percent of time below therapeutic range, 29.8% vs. 29.2%. However, the primary care practice patients were above the therapeutic range 15% of the time vs. 10% in cardiology (p b 0.001). There were one death secondary to intracranial bleed and one major bleed in the primary care group. There were no strokes during the study period in either group. Conclusion: The QoA with warfarin, as assessed by TTR, in the current community setting remains suboptimal, and there has been little to no improvement in current clinical practices. TTR should be considered when assessing the recent comparative studies evaluating novel pharmacologic agents to warfarin for the treatment of AF. Subject Areas: Arrhythmias, preventive cardiology, anticoagulation, thromboembolism, cardiovas- cular disease risk factors. © 2013 Elsevier Inc. All rights reserved. Keywords: Anticoagulants; Warfarin; VKA; INR; Atrial fibrillation; Stroke prevention and time in therapeutic range Introduction Atrial fibrillation (AF) affects approximately 2.3 million adults with a prevalence exceeding 10% among those aged 75 years and older. 1,2 AF increases the risk for ischemic stroke nearly 5-fold 3 and accounts for approximately 15% of Available online at www.sciencedirect.com Journal of Electrocardiology 46 (2013) 45 – 50 www.jecgonline.com ⁎ Corresponding author. Division of Cardiology, New York Methodist Hospital, Brooklyn, NY 11215-9008, USA. E-mail address: john.heitner@gmail.com 0022-0736/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jelectrocard.2012.08.011