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Background  Warfarin reduces ischemic stroke risk in atrial fibrillation ( AF ) but increases bleeding risk. Novel anticoagulants challenge warfarin as stroke‐preventive therapy for  AF . They are available at fixed doses but are more costly. Warfarin anticoagulation at a time in therapeutic range ( TTR ) ≥70% is similarly as effective and safe as novel anticoagulants. It is unclear whether  AF  patients with  TTR  ≥70% will remain stably anticoagulated and avoid the need to switch to a novel anticoagulant. We assessed stability of warfarin anticoagulation in  AF  patients with an initial  TTR  ≥70%.    Methods and Results  Within the community‐based Anticoagulation and Risk Factors in AF (ATRIA) cohort followed from 1996 to 2003, we identified 2841 new warfarin users who continued warfarin over 9 months. We excluded months 1 to 3 to achieve a stable dose. For the 987 patients with TTR ≥70% in an initial 6‐month period ( TTR  1 ; months 4–9), we described the distribution of  TTR  2  (months 10–15) and assessed multivariable correlates of persistent  TTR  ≥70%. Of patients with  TTR  1  ≥70%, 57% persisted with  TTR  2  ≥70% and 16% deteriorated to  TTR  2  <50%. Only initial  TTR  1  ≥90% (adjusted odds ratio 1.47, 95% CI 1.07–2.01) independently predicted  TTR  2  ≥70%. Heart failure was moderately associated with marked deterioration ( TTR  2  <50%); adjusted odds ratio 1.45, 95% CI 1.00–2.10.    Conclusions  Nearly 60% of  AF  patients with high‐quality  TTR 1   on warfarin maintained  TTR  ≥70% over the next 6 months. A minority deteriorated to very poor  TTR . Patient features did not strongly predict  TTR  in the second 6‐month period. Our analyses support watchful waiting for  AF  patients with initial high‐quality warfarin anticoagulation before considering alternative anticoagulants.

journal of the american heart association

Stability of High‐Quality Warfarin Anticoagulation in a Community‐Based Atrial Fibrillation Cohort: The Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study