Anticoagulation for newly diagnosed atrial fibrillation and 90-day rates of stroke and bleeding.

Abstract

Atrial fibrillation increases the risk of stroke, which can be mitigated by anticoagulant prescription. We evaluated local emergency physician anticoagulation practice for patients discharged from the emergency department with atrial fibrillation, along with 90-day incidence of stroke and major bleeding. This was a health record review of patients diagnosed with new onset atrial fibrillation in two emergency departments between 2014 and 2017. We collected data on CHADS65 scores, contraindications to direct oral anticoagulant (DOAC) prescription and initiation of anticoagulation in the ED. Patient charts were reviewed for the diagnosis of stroke, transient ischemic attack (TIA), systemic embolism or major bleeding within 90days. We identified 399 patients, median age 68 (IQR 57-79), 213 (53%) male. Only 299/399 patients had an indication for anticoagulation (CHADS65-positive). Of these 299, 27 had a contraindication to or were already prescribed anticoagulation. 45/272 (17%, 95% confidence interval 12-22%) patients eligible for initiation of anticoagulation left the emergency department with a prescription for anticoagulation. During 90-day follow-up, seven patients had stroke or TIA. Four stroke/TIA patients had been eligible to start an anticoagulant but were not started, two left the emergency department with prescriptions for an anticoagulant and one patient had a contraindication to initiating anticoagulation in the emergency department. There were no major bleeding episodes. Few eligible patients were prescribed anticoagulation and the 90-day stroke rate was high. Physicians should become familiar with the CAEP Acute AF Best Practices Checklist AF which offers guidance on anticoagulation prescription.