Despite these concerns, there is often a misunderstanding about the net clinical benefit associated with oral anticoagulation in the elderly.Physicians often cite perceived bleeding risk as a primary reason for withholding anticoagulation for AF/FL patients, a finding we also observed.Physicians overestimate the risk of intracranial bleeding in patients with high risk for falls. However, there is evidence that patients with AF would need to fall repeatedly throughout the year before the risk of intracranial hemorrhage would outweigh the net benefits of stroke-prevention from anticoagulation.Of interest, a patient’s predicted hemorrhage risk, as measured by the HAS-BLED score, was associated with less anticoagulation prescribing in our population but was of borderline statistical significance. The evidence suggests that a high-risk HAS-BLED score per se is not a reason to withhold anticoagulation that is otherwise indicated.In most patients with elevated bleeding risks, the magnitude of gain from stroke reduction far outweighs the small risk of serious bleeding.Bleeding risk scores are best used to identify patients in need of closer follow-up, particularly to address reversible risk factors such as uncontrolled hypertension, concomitant use of non-steroidal anti-inflammatory medications, and excess alcohol.Our study found that several rhythm-related characteristics were strongly associated with the likelihood of receiving oral anticoagulation at or shortly after an ED visit for AF/FL. For example, we noted that patients who reverted to sinus rhythm before ED discharge were less likely to receive a prescription for anticoagulation. As indicated from the reasons documented for withholding anticoagulation, EPs significantly varied their estimation of a patient’s ischemic stroke risk based on the persistence of AF/FL during the ED stay.

Lower rates of anticoagulation also have been seen in patients with paroxysmal AF in other practice settings.Most recently,cannabis equipment an analysis of the American College of Cardiology PINNACLE Registry found that patients with paroxysmal AF considered at a moderate to high risk of ischemic stroke were less likely to be prescribed oral anticoagulant therapy and more likely to be prescribed less effective or no therapy for thromboembolism prevention than those with non-paroxysmal AF.Compared with patients with persistent or permanent AF, those with paroxysmal AF have less frequent and less prolonged episodes of AF , which correlates with a lower incidence of thromboembolism.Yet the reduction in stroke risk is not sufficient to lessen the need for thromboprophylaxis.Importantly, consensus-based clinical practice guidelines do not vary their recommendations for thromboprophylaxis based on type of AF, nor do validated stroke risk scores alter their prognosis based on paroxysmal or non-paroxysmal rhythm.We also found that physicians were less likely to initiate anticoagulation in patients with a history of prior AF/FL and in those whose atrial dysrhythmia was thought by the EP to be chronic and unremitting. This might seem counter intuitive given our finding that patients who left the ED still in AF/FL were more likely to receive thromboprophylaxis. It is possible, however, that ED patients at high risk for stroke with known recurrent or chronic AF/FL had already been advised about anticoagulation options before their index ED visit and previously declined or discontinued anticoagulation in the distant past. Some have attributed this behavior to “clinical inertia,” the hesitancy of physicians to alter the current pattern of care initiated by other providers.Nonetheless, further exploration is needed to clarify the underlying reasons for these observations. With today’s expanded pharmacopeia for AF/FL stroke prevention, patients who had declined or discontinued warfarin in the past may be open to consider a direct oral anticoagulant, given the several patient-oriented advantages of this class of medications.

One novel finding of our study is that EPs were more likely to initiate anticoagulation when consulting cardiology. The reason for this may be multifactorial. Certain patients may have a clinical profile that leads to both cardiology consultation and thromboprophylaxis, or perhaps EPs who consult cardiology are more apt to initiate anticoagulation independent of the consultation. The more likely reason, however, is that cardiologists asked to advise on any facet of ED AF/FL care may raise the question of stroke risk and recommend thromboprophylaxis when indicated.Others have shown that cardiology involvement in the outpatient setting improves rates of stroke prevention treatment in AF patients. The TREAT-AF study found that outpatient cardiology care compared with primary care was associated with higher rates of anticoagulation of AF patients.Anticoagulation rates increase even when a primary care provider referred their AF/FL patients to see a cardiologist but maintained patient oversight themselves.The benefits of multi-specialty collaboration were seen not just during the patients’ ED stay. Of those who were prescribed oral anticoagulation in this study, more than one quarter were given thromboprophylaxis in the outpatient setting, either in the primary care or cardiology clinics. The importance of post-ED follow-up for AF/FL patients at high risk for thromboembolism is also seen by the number of EPs and patients in our study who deferred the anticoagulation decision to allow a fuller discussion of thromboprophylaxis with an outpatient provider. Deferring the initiation of anticoagulation in high-risk ED patients, however, may not be without risk. In some settings, a significant proportion of AF patients discharged home from the ED failed to achieve outpatient follow-up in the subsequent 90 days, regardless of insurance status.Moreover, compared with patients who leave the ED with an anticoagulant prescription in hand,vertical grow shelf those who wait to consult an outpatient provider about stroke prevention have been shown to have a significantly lower frequency of long-term anticoagulation use and a significant delay in initiation among those eventually treated.

When referring patients to outpatient providers for this critical decision, the EP can facilitate anticoagulation initiation by several means: introducing stroke prevention to their AF/ FL patients and beginning the educational and shared decision-making process; including stroke prevention material in the patient’s discharge instructions; recommending a timely follow-up appointment; and notifying the outpatient provider that stroke prevention may be indicated and that patient education was begun prior to ED discharge.Our results highlight opportunities for improvement in care. Patients seeking emergency care for their AF/FL may be more open to health-promoting behavioral changes, as has been observed with other medical conditions.Initiating stroke-prevention therapy at the time of ED discharge has been shown to be safe and associated with a mortality reduction.Not all EPs, however, see it as their role to initiate anticoagulation when indicated for AF/FL patients.Nevertheless, EPs can still play a key role in promoting stroke prevention by risk-stratifying their AF/FL patients, broaching the topic with high-risk patients, adding personalized stroke risk educational material to the discharge instructions, and encouraging high-risk patients to continue the shared decision making conversation about thromboprophylaxis with their outpatient provider. The results of this study raise questions about other ways to increase evidence-based anticoagulation. We identified certain physician misunderstandings that, if corrected, could increase anticoagulation of stroke-prone patients with AF/FL. Physician education should emphasize that patients with AF/ FL at high risk for thromboembolism warrant stroke prevention even if their rhythm type is paroxysmal.Also, antiplatelet agents do not provide sufficient protection against ischemic stroke in patients with high-risk AF/FL, though this is commonly believed.We observed that about one in eight high-risk AF/FL patients were given or continued on aspirin instead of oral anticoagulation, a high percentage, but lower than that found in a large cardiology clinic-based population of AF patients at moderate to high risk of stroke.Unfortunately, we were not able to distinguish when aspirin was advised as though it were sufficient stroke prevention from cases where the patient refused anticoagulation and was recommended aspirin instead. Recent U.S. guidelines suggest a very limited role for aspirin in selected AF/FL patients ;3 data supporting the use of aspirin monotherapy in patients at high risk of stroke are poor, and there are reports that it may even increase the risk of ischemic stroke in elderly patients.Aspirin is also not safer than oral anticoagulation in patients over 80 years of age with regard to serious bleeding.Recent guidelines recommend that aspirin monotherapy should not be used as stroke prevention in AF/FL with the exception of patients who refuse any form of oral anticoagulation and cannot tolerate a combination of aspirin and clopidogrel.Though education about these misunderstandings will be vital, education alone may ultimately have little impact on changing physician behavior.Several academic medical centers have improved oral anticoagulation rates in stroke prone AF patients by referring them to an accessible outpatient AF clinic.Another recommended approach is the provision of electronic clinical decision support to help physicians in their care for AF/FL patients.

To facilitate AF/FL thromboprophylaxis, such a system could calculate a patient’s predicted stroke and bleeding risk scores simultaneously at the point of care and provide patient-specific recommendations for treatment. Results of various clinical decision support systems have been mixed.The Anticoagulant Programme East London, for example, showed improvement in appropriate anticoagulation of outpatients with AF by a combined program of education around agreed-upon guidelines with computer aids to facilitate decision-making as well as patient-specific review and feedback of locally identifiable results.Some clinical researchers are sharing their electronic clinical decision support tools for AF stroke prevention with patients and have found that mobile health technology improved patient knowledge, drug adherence, anticoagulant satisfaction, and quality of life.Electronic clinical decision support tools have had success in the ED setting when combined with a strong promotional program and could be readily adapted for use in patients with AF/FL.A multidisciplinary team at the University of British Columbia designed such an electronic clinical care pathway for ED patients with uncomplicated AF/FL.The pathway included a care map, decision aids, medication orders, management suggestions, and electronic consultation or referral documents, embedded in the computerized physician order entry and integrated electronic health record. Implementation was preceded and accompanied by a standardized educational and promotional program. The pathway increased the incidence of anticoagulation initiation on discharge for high-risk patients by 20.6 percentage points.This study had several limitations. The study sample did not include all identified AF/FL patients; however, patient characteristics were highly similar between those who were and were not enrolled, so the impact of potential selection bias is likely limited. Our prospective data collection tool was designed to evaluate a wide range of care-related issues for AF/FL and was not focused on thromboprophylaxis , but we cannot rule out the potential for a Hawthorne effect during the study period. The sample size was modest, which accounts for limited precision for certain associations, and we cannot rule out missing associations of smaller magnitude that may still be clinically relevant. We did not prospectively capture each patient’s relative contraindications to anticoagulation or their treatment preferences, which are two of the leading reasons physicians deviate from guideline recommendations for stroke prevention therapy.This enlarged our denominator of anticoagulant-eligible patients and lowered our percentage of anticoagulant prescribing. We were able to identify some of these contraindications during our retrospective chart review, but these variables were incompletely documented. This study focused on stroke prevention using warfarin, the only oral anticoagulant on the formulary in our health system until early 2014. Even with the recent availability of direct oral anticoagulants, physicians in our health system continue to initiate warfarin for AF/FL thromboprophylaxis: 40% of new oral anticoagulant prescriptions during the first quarter of 2017 for non-valvular AF/FL across all 21 medical centers were for warfarin. Warfarin continues to be widely used for stroke prevention across North America, Europe, and around the world.In fact, the European Society of Cardiology says it is reasonable to continue warfarin therapy in AF patients with a reassuring time in therapeutic range.It is unclear whether the availability of newer agents will substantively alter physician overestimation of bleeding risk in older patients or underestimation of long-term stroke risk in patients with paroxysmal AF. Additional research will be needed to evaluate whether practice patterns of stroke prevention in AF/FL patients will change with use of direct oral anticoagulants. Studies suggest, however, that sub-optimal AF thromboprophylaxis persists despite the availability of direct oral anticoagulants. 90 Lastly, our study was conducted in a large integrated healthcare delivery system in California among insured patients who, on ED discharge, can receive close monitoring by our pharmacy-led Outpatient Anticoagulation Service and timely follow-up with their primary care providers. These integrated services may influence ED prescribing practices and may not be readily available to patients and providers in other healthcare systems. These distinctions of care may limit the generalizability of our results to other geographic locations and practice settings.