Abstract
IntroductionMany patients with atrial fibrillation or atrial flutter (AF/FL) who are high risk for ischemic stroke are not receiving evidence-based thromboprophylaxis. We examined anticoagulant prescribing within 30 days of receiving dysrhythmia care for non-valvular AF/FL in the emergency department (ED).MethodsThis prospective study included non-anticoagulated adults at high risk for ischemic stroke (ATRIA score ≥7) who received emergency AF/FL care and were discharged home from seven community EDs between May 2011 and August 2012. We characterized oral anticoagulant prescribing patterns and identified predictors of receiving anticoagulants within 30 days of the index ED visit. We also describe documented reasons for withholding anticoagulation.ResultsOf 312 eligible patients, 128 (41.0%) were prescribed anticoagulation at ED discharge or within 30 days. Independent predictors of anticoagulation included age (adjusted odds ratio [aOR] 0.89 per year, 95% confidence interval [CI] 0.82–0.96); ED cardiology consultation (aOR 1.89, 95% CI [1.10–3.23]); and failure of sinus restoration by time of ED discharge (aOR 2.65, 95% CI [1.35–5.21]). Reasons for withholding anticoagulation at ED discharge were documented in 139 of 227 cases (61.2%), the most common of which were deferring the shared decision-making process to the patient’s outpatient provider, perceived bleeding risk, patient refusal, and restoration of sinus rhythm.ConclusionApproximately 40% of non-anticoagulated AF/FL patients at high risk for stroke who presented for emergency dysrhythmia care were prescribed anticoagulation within 30 days. Physicians were less likely to anticoagulate older patients and those with ED sinus restoration. Opportunities exist to improve rates of thromboprophylaxis in this high-risk population.
Highlights
Many patients with atrial fibrillation or atrial flutter (AF/FL) who are high risk for ischemic stroke are not receiving evidence-based thromboprophylaxis
We examined anticoagulant prescribing within 30 days of receiving dysrhythmia care for non-valvular Atrial fibrillation (AF)/FL in the emergency department (ED)
Approximately 40% of non-anticoagulated atrial fibrillation or flutter (AF/FL) patients at high risk for stroke who presented for emergency dysrhythmia care were prescribed anticoagulation within 30 days
Summary
Many patients with atrial fibrillation or atrial flutter (AF/FL) who are high risk for ischemic stroke are not receiving evidence-based thromboprophylaxis. Non-anticoagulated patients with AF/FL commonly seek rhythm-related care in the emergency department (ED).[15,20,21,22] AF patients who present for emergency care have a higher incidence of stroke and death than patients seen in other venues.[23] In some settings, more than half of AF patients discharged from the ED fail to achieve outpatient follow-up within 90 days of discharge, regardless of insurance status.[24] In such cases, an ED visit may provide a critical opportunity for a stroke-prevention intervention Such encounters may serve as a sentinel event for those at high risk for stroke, facilitating important changes in their health behavior.[25,26,27,28,29,30] Physicians can seize on such teachable moments to educate high-risk AF/FL patients on stroke risk and prevention and, when appropriate, to recommend or prescribe anticoagulation.[15, 31]
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