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

Abstract

Background

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.

Methods

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 90 days.

Results

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.

Conclusion

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.

Résumé

Contexte

La fibrillation auriculaire augmente le risque d'accident vasculaire cérébral, qui peut être atténué par la prescription d'anticoagulants. Nous avons évalué la pratique d'anticoagulation des médecins d'urgence locaux pour les patients sortis du service d'urgence avec la fibrillation auriculaire, ainsi que l'incidence sur 90 jours d’AVC et des saignements majeurss.

Méthodes

Il s'agissait d'un examen du dossier de santé des patients diagnostiqués avec une nouvelle apparition de la fibrillation auriculaire dans deux services d'urgence entre 2014 et 2017. Nous avons recueilli des données sur les scores CHADS65, les contre-indications à la prescription d’anticoagulants oraux directs (AOD) et l'initiation de l'anticoagulation au service des urgences. Les fiches des patients ont été revues pour le diagnostic d'AVC, d'accident ischémique transitoire (AIT), d'embolie systémique d'hémorragie majeure dans les 90 jours.

Résultats

Nous avons identifié 399 patients, d'âge médian 68 (IQR 57-79), 213 (53 %) hommes. Seuls 299/399 patients avaient une indication d'anticoagulation (CHADS65 positif). Sur ces 299, 27 présentaient une contre-indication ou se voyaient déjà prescrire une anticoagulation. 45/272 (17 %, 95 % intervalle de confiance de 12 % à 22 %) patients éligibles pour l'initiation de l'anticoagulation ont quitté avec une prescription d'anticoagulation. Au cours du suivi de 90 jours, sept patients ont eu un accident vasculaire cérébral ou un AIT. Quatre patients ayant subi un AVC / AIT étaient éligibles pour commencer un anticoagulant mais qui n'ont pas été commencés, deux ont quitté le service des urgences avec des ordonnances d'un anticoagulant et un patient avait une contre-indication à l'initiation de l'anticoagulation au service des urgences. Il n'y a pas eu d'épisodes d’hémorragie majeure.

Conclusion

Peu de patients éligibles se sont vu prescrire une anticoagulation et le taux d’AVC durant les 90 jours était élevé. Les médecins doivent se familiariser avec la liste de contrôle des meilleures pratiques pour la CAEP FA aiguë qui offre des conseils sur la prescription des anticoagulations.

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Funding

This hospital quality improvement program is funded by a grant from Bayer.

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Correspondence to Kerstin de Wit.

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Conflict of interest

Bayer manufacture rivaroxaban which is an anticoagulant used in the prevention of stroke for patients with atrial fibrillation.

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Niaz, S., Kirwan, C., Clayton, N. et al. Anticoagulation for newly diagnosed atrial fibrillation and 90-day rates of stroke and bleeding. Can J Emerg Med (2021). https://doi.org/10.1007/s43678-020-00054-y

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Keywords

  • Atrial fibrillation
  • Anticoagulation
  • Stroke