Stopping Warfarin in Dementia Patients with Atrial Fib Associated With Increased Risk of Stroke and Death Interview with:

Ariela Orkaby, MD, MPH Geriatrics & Preventive Cardiology Associate Epidemiologist Division of Aging, Brigham and Women's Hospital Instructor in Medicine, Harvard Medical School

Dr. Ariela Orkaby

Ariela Orkaby, MD, MPH
Geriatrics & Preventive Cardiology
Associate Epidemiologist
Division of Aging, Brigham and Women’s Hospital
Instructor in Medicine, Harvard Medical School What is the background for this study? What are the main findings?

Response: Atrial Fibrillation is a common heart rhythm that affects 1 in 25 adults over age 60 and 1 in 10 adults over age 80. The feared consequence of atrial fibrillation is stroke, leading to the prescription of blood thinning medications (anticoagulants such as warfarin) to prevent strokes. However, there is an underutilization of these life-saving medications in older adults, and particularly in those who have dementia. In part, this is due to a lack of research and inclusion of older adults with dementia in prior studies.

In this study, we used clinical Veterans Administration data, linked to Medicare, to follow 2,572 individuals over age 65 who had atrial fibrillation and until a diagnosis of dementia. The average age was 80 years, and 99% were male. We found that only 16% remained on warfarin. We used statistical methods to account for reasons why a patient would or would not be treated with warfarin and found that those who continued to take warfarin had a significantly lower risk of stroke (HR 0.74, 95% Confidence interval 0.54- 0.99, p=0.47) and death (HR 0.72, 95% CI 0.60-0.87, p<0.01) compared to those who did not continue to take warfarin, without an increased risk of bleeding. What should readers take away from your report?

Response: Stopping warfarin in patients with atrial fibrillation after a diagnosis of dementia is associated with an increased risk of stroke and death. Importantly we did not see an increased risk of bleeding in those who continued to take warfarin. What recommendations do you have for future research as a result of this study?

Response: There is a need for randomized trials of anticoagulation therapy for atrial fibrillation stroke prevention in the very old, and particularly those with dementia. This is particularly important as novel anticoagulants are increasingly being used, and little is known about their risk of benefit in the very old or those with dementia. Is there anything else you would like to add?

Response: Older adults, particularly those with dementia must be included in clinical trials of cardiovascular disease treatments as they are often the target group for the therapies studied, but clinicians are left to extrapolate from studies of younger and often healthier individuals.

No relevant disclosures. Thank you for your contribution to the community.

Continued Use of Warfarin in Veterans with Atrial Fibrillation After Dementia Diagnosis
Ariela R. Orkaby MD, Al Ozonoff PhD, Joel I. Reisman AB, Donald R. Miller ScD, Shibei Zhao MPH and Adam J. Rose MD, MSc
Version of Record online: 30 DEC 2016
DOI: 10.1111/jgs.14573
J Am Geriatr Soc 65:249–256, 2017

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Last Updated on February 26, 2017 by Marie Benz MD FAAD