PRESCRIPTION OF ORAL ANTICOAGULATION IN PATIENTS WITH A PRIMARY OR SECONDARY DIAGNOSIS OF ATRIAL FIBRILLATION WHO ATTEND THE EMERGENCY DEPARTMENT
CCC ePoster Library. Mendoza P. 10/26/19; 280539; 304
Pablo Mendoza
Pablo Mendoza
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Abstract
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BACKGROUND: Oral anticoagulation (OAC) is often initiated for stroke prevention when atrial fibrillation (AF) is diagnosed. The rate of OAC initiation in the emergency department (ED) is assumed to be low, particularly when patients present with AF as a secondary diagnosis.

METHODS AND RESULTS: Among patients presenting with AF as a primary or secondary diagnosis, we determined: i) proportion of patients prescribed OAC, ii) factors associated with OAC prescription at ED discharge, and iii) clinical outcomes. In the RE-LY AF registry, we used multivariable analysis to determine predictors of OAC prescription. We compared OAC prescription and clinical outcomes between patients presenting to the ED with AF as their main diagnosis (primary AF), or presenting with another chief complaint and concurrent AF (secondary diagnosis of AF). Among 15,400 patients from 47 countries in the RE-LY AF registry, we excluded all patients already taking OAC. Patients with new onset, secondary diagnosis of AF were also excluded if their primary diagnosis was ischemic stroke, systemic embolism, a cardiac admitting diagnosis (i.e. myocardial infarction, heart failure, pericarditis, arrhythmia) or stage V chronic kidney disease. Based on our analysis, ED prescription of OAC for both primary and secondary AF occurred in about one quarter of cases (24.7% to 25.8%, p=0.477). Among 5174 patients with a primary diagnosis of AF: specialist referral for AF (relative risk (RR) 2.42, 95%CI 1.90-3.09), rheumatic heart disease (RR 2.02, 95%CI 1.69-2.42), AF on discharge (RR 1.46, 95%CI 1.31-1.64), diabetes (RR 1.32, 95%CI 1.19-1.47) and hypertension (RR 1.16, 95%CI 1.04-1.30) were predictors of OAC prescription, while cognitive dysfunction (RR 0.58, 95%CI 0.37-0.90) and pre-existing anti-platelet agent use (RR 0.77 95%CI 0.70-0.84) was inversely associated with prescription. Among 962 patients with a secondary diagnosis of AF: specialist referral for AF (RR 2.65, 95%CI 1.70-4.14), rheumatic heart disease (RR 1.66, 95%CI 1.12-2.47), and AF on discharge (RR 1.83, 95%CI 1.29-2.59) were predictors, while cognitive dysfunction (RR 0.21 95%CI 0.05-0.82) was inversely associated with OAC prescription. At 1 year, OAC use was significantly lower in patients with primary versus secondary AF (26.6% vs. 31.2%, p=0.003). Patients with a secondary diagnosis of AF had significantly higher rates of death, major bleeding and hospitalization for heart failure at 1 year (Table 1).

CONCLUSION: Among patients who attended the ED, prescription of OAC for AF patients was low, but appeared higher with specialist referral. A secondary diagnosis of AF portends a worse prognosis at 1 year.
BACKGROUND: Oral anticoagulation (OAC) is often initiated for stroke prevention when atrial fibrillation (AF) is diagnosed. The rate of OAC initiation in the emergency department (ED) is assumed to be low, particularly when patients present with AF as a secondary diagnosis.

METHODS AND RESULTS: Among patients presenting with AF as a primary or secondary diagnosis, we determined: i) proportion of patients prescribed OAC, ii) factors associated with OAC prescription at ED discharge, and iii) clinical outcomes. In the RE-LY AF registry, we used multivariable analysis to determine predictors of OAC prescription. We compared OAC prescription and clinical outcomes between patients presenting to the ED with AF as their main diagnosis (primary AF), or presenting with another chief complaint and concurrent AF (secondary diagnosis of AF). Among 15,400 patients from 47 countries in the RE-LY AF registry, we excluded all patients already taking OAC. Patients with new onset, secondary diagnosis of AF were also excluded if their primary diagnosis was ischemic stroke, systemic embolism, a cardiac admitting diagnosis (i.e. myocardial infarction, heart failure, pericarditis, arrhythmia) or stage V chronic kidney disease. Based on our analysis, ED prescription of OAC for both primary and secondary AF occurred in about one quarter of cases (24.7% to 25.8%, p=0.477). Among 5174 patients with a primary diagnosis of AF: specialist referral for AF (relative risk (RR) 2.42, 95%CI 1.90-3.09), rheumatic heart disease (RR 2.02, 95%CI 1.69-2.42), AF on discharge (RR 1.46, 95%CI 1.31-1.64), diabetes (RR 1.32, 95%CI 1.19-1.47) and hypertension (RR 1.16, 95%CI 1.04-1.30) were predictors of OAC prescription, while cognitive dysfunction (RR 0.58, 95%CI 0.37-0.90) and pre-existing anti-platelet agent use (RR 0.77 95%CI 0.70-0.84) was inversely associated with prescription. Among 962 patients with a secondary diagnosis of AF: specialist referral for AF (RR 2.65, 95%CI 1.70-4.14), rheumatic heart disease (RR 1.66, 95%CI 1.12-2.47), and AF on discharge (RR 1.83, 95%CI 1.29-2.59) were predictors, while cognitive dysfunction (RR 0.21 95%CI 0.05-0.82) was inversely associated with OAC prescription. At 1 year, OAC use was significantly lower in patients with primary versus secondary AF (26.6% vs. 31.2%, p=0.003). Patients with a secondary diagnosis of AF had significantly higher rates of death, major bleeding and hospitalization for heart failure at 1 year (Table 1).

CONCLUSION: Among patients who attended the ED, prescription of OAC for AF patients was low, but appeared higher with specialist referral. A secondary diagnosis of AF portends a worse prognosis at 1 year.
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