Outcomes in atrial fibrillation patients on combined warfarin & antiarrhythmic therapy

Background This retrospective cohort study compared rates of treatment persistence, incidences of de novo stroke, arterial embolism, and hemorrhage/bleeding, and healthcare resource use and costs between atrial fibrillation/flutter (AF/AFL) patients receiving concomitant warfarin (W)+amiodarone (A) or warfarin+other antiarrhythmic drug (OAAD) therapy in real-world practice. Methods The Ingenix IMPACT database (1997–2009) was used to identify patients with ≥1 diagnostic claim for AF/AFL and concurrent pharmacy claims (≥60days' supply) for W and A (n=4238) or W+OAAD (n=6332) within the first 90days of initiating therapy. Outcomes of interest were assessed over 12months following initiation of dual therapy. Results The W+A cohort was older than the W+OAAD cohort (mean 66.5 vs. 61.9years) and had greater baseline comorbidity. The W+A cohort had significantly 1) lower rates of treatment persistence; 2) higher incidences of de novo stroke (hazard ratio [HR] 1.24), arterial embolism (HR 1.48) and combined stroke/hemorrhage/bleeding/arterial embolism (HR 1.25); 3) more frequent inpatient (incidence rate ratio [IRR] 1.25), emergency room (IRR 1.16) and outpatient (IRR 1.07) admissions; and 4) higher incidences of cardiovascular- (IRR 1.35) and arterial embolism- (IRR 1.94) related healthcare use than the W+OAAD cohort. Incremental total healthcare costs over 12months were $4114 ($2397 inpatient; $1171 outpatient). Conclusions Allowing for differences in prescribing practice, AF/AFL patients treated with W+A are at higher risk of stroke and arterial embolism, and have higher healthcare use and costs, than patients receiving W+OAAD.