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Stroke Prophylaxis in Atrial Fibrillation: Searching for Management Improvement Opportunities in the Emergency Department: The HERMES-AF Study

2014; Elsevier BV; Volume: 65; Issue: 1 Linguagem: Inglês

10.1016/j.annemergmed.2014.07.016

1097-6760

Blanca Coll‐Vinent, Alfonso Martı́n, Francisco Malagón, Coral Suero, Juan Carlos Martín‐Sánchez, Mercedes Varona, Manuel Cancio, Susana Sánchez‐Fidalgo, Eugeni Montull, Carmen del Arco, Coral Suero, Emilio Román, F. Heredia, Ana Ma Sagarra, Ángel Estella, Francisco Manuel Brun, Elías Simón, José Manuel Torres, Elisa Lopera Lopera, Fuensanta Soriano, Fernando Santamarina, Juan Carlos Martín‐Sánchez, Matilde F. Feixas, F. Javier Hierro, José Ma Santos, Álvaro F. Perea, Francisco Tembury, Macarena Rizo, Adolfo Ramirez, Rafael Sindiones, Francisco Moya, Amparo Fernández, Francisco Ruiz, José Manuel Garrido, Enrique Almagro, Javier Povar, Elisa Aldea, Miguel Rivas, Fernando Galve, Manuel Múñoz, Juan Alberto García, Pedro Cals, A. Alonso Gutiérrez, Luis Garcı́a-Castrillo, María José Rodriguez, Fernando Richard, Beatriz López, Luis Lapuerta, Tomás Toranzo, Nicanor Zapico, Susana Sánchez‐Fidalgo, Ana Melendre, José Manuel Varela Aguilar, Ma del Mar Sousa, Alberto Lopez, Luis Caminal‐Montero, Raimundo Rodriguez-Bobada, Ramón Perales, Rosa Roldán, Carolina Fuenzalida, Olga Trejo, Alfons Aguirre, Teresa Soriano, Mireia Margelí Vila, Lluis Fornet, Francisco Casarramona, Ma. Isabel Barrionuevo Sánchez, Julio Font, Joan Espinach, Mercè Almirall, J Danes, Álvaro Herrera, Silvia Macotela Flores, Ali Jammoul, Jose Hervas Vicente, Ma Isabel Campos, Rafael Colomina, Joaquín Escámez, Begoña Arcos, Ma Carmen Navarro, Javier Millán, Jose Javier Noceda, Salvador Rubini, Ricardo Rubini, José Carbajosa, Ma Elena Díaz, Francisco José Navarro, M del Mar AIRES GONZÁLEZ, Adelaida Mateo, Cristina Gisbert, Francisco Navarro, Mercedes Varona, Manuel Cancio, José I. López, Francisco David Muñoz, Ma Teresa García, Pablo Lamas, Luis F. Amador, Ricardo Calvo, Carmen Seijas, Ma C. Selloso, Manuel García, Francisco José Aramburu, Ma A. Leciñena, Alex Planas, Ignacio Ayala, José Alonso, Benito Gutiérrez, Pedro Marco, Belén Rodríguez, Carmen del Arco, Juan Manuel Soto Parra, Juan González, Leonardo Mejia Rincon, Oscar Álvarez, Juan Antonio Andueza, J. Alvear Garcia, Gregorio Jiménez, Alfonso Martı́n, Francisco Malagón, Manuel Ruizy, Esther Mora, Juan Torres, Jesús Canora, Carlos Bibiano, Pascual Piñera, Enrique Retuerto, Jose Ma Melgares, Jesús Cruzado, Carmen Escudero, Ángel Alonso Hernández, Eduardo García Jiménez, J.F. Martínez López,

Venous Thromboembolism Diagnosis and Management

Study objective We determine the prevalence of stroke prophylaxis prescription in emergency department (ED) patients with atrial fibrillation and the factors associated with a lack of prescription of anticoagulation in high-risk patients without contraindications. Methods This was a multicenter, observational, cross-sectional study with prospective standardized data collection carried out in 124 Spanish EDs. Clinical variables, risk factors for stroke, type of prophylaxis prescribed, and reasons for not prescribing anticoagulation in high-risk patients (congestive heart failure/left ventricular dysfunction, hypertension, age >75 years, diabetes and previous stroke/transient ischemic attack/systemic embolism [CHADS2] score ≥2 and the congestive heart failure/left ventricular dysfunction, hypertension, age >75 years, diabetes, previous stroke/transient ischemic attack/systemic embolism, vascular disease age 65 to 74 years and sex category [CHA2DS2-VASc] score ≥2) without contraindications were collected. Results Of 3,276 patients enrolled, 71.5% were at high risk according to CHADS2; 89.7% according to CHA2DS2-VASc. At discharge from the ED, 2,255 patients (68.8%) were receiving anticoagulants, 1,691 of whom (75%) were high-risk patients. Of the 1,931 patients discharged home, anticoagulation was prescribed for 384 patients (19.9%) de novo and for 932 patients (48.3%) previously receiving anticoagulation. The main reasons for not prescribing anticoagulation to eligible patients were considering antiplatelet therapy as adequate prophylaxis (33.1%), advanced age (15%), and considering stroke risk as low (8.3%). Advanced age (odds ratio 0.46; 95% confidence interval 0.30 to 0.69) and female sex (odds ratio 0.50; 95% confidence interval 0.36 to 0.71) were significantly associated with the lack of prescription of anticoagulation to eligible patients. Conclusion In Spain, most patients with atrial fibrillation treated in EDs who do not receive anticoagulation are at high risk of stroke, with relevant differences with regard to the risk stratification scheme used. Anticoagulation is underused, mainly because the risk of stroke is underestimated by the treating physicians and the benefits of antiplatelets are overrated, principally in female patients and the elderly. Efforts to increase the prescription of anticoagulation in these patients appear warranted. We determine the prevalence of stroke prophylaxis prescription in emergency department (ED) patients with atrial fibrillation and the factors associated with a lack of prescription of anticoagulation in high-risk patients without contraindications. This was a multicenter, observational, cross-sectional study with prospective standardized data collection carried out in 124 Spanish EDs. Clinical variables, risk factors for stroke, type of prophylaxis prescribed, and reasons for not prescribing anticoagulation in high-risk patients (congestive heart failure/left ventricular dysfunction, hypertension, age >75 years, diabetes and previous stroke/transient ischemic attack/systemic embolism [CHADS2] score ≥2 and the congestive heart failure/left ventricular dysfunction, hypertension, age >75 years, diabetes, previous stroke/transient ischemic attack/systemic embolism, vascular disease age 65 to 74 years and sex category [CHA2DS2-VASc] score ≥2) without contraindications were collected. Of 3,276 patients enrolled, 71.5% were at high risk according to CHADS2; 89.7% according to CHA2DS2-VASc. At discharge from the ED, 2,255 patients (68.8%) were receiving anticoagulants, 1,691 of whom (75%) were high-risk patients. Of the 1,931 patients discharged home, anticoagulation was prescribed for 384 patients (19.9%) de novo and for 932 patients (48.3%) previously receiving anticoagulation. The main reasons for not prescribing anticoagulation to eligible patients were considering antiplatelet therapy as adequate prophylaxis (33.1%), advanced age (15%), and considering stroke risk as low (8.3%). Advanced age (odds ratio 0.46; 95% confidence interval 0.30 to 0.69) and female sex (odds ratio 0.50; 95% confidence interval 0.36 to 0.71) were significantly associated with the lack of prescription of anticoagulation to eligible patients. In Spain, most patients with atrial fibrillation treated in EDs who do not receive anticoagulation are at high risk of stroke, with relevant differences with regard to the risk stratification scheme used. Anticoagulation is underused, mainly because the risk of stroke is underestimated by the treating physicians and the benefits of antiplatelets are overrated, principally in female patients and the elderly. Efforts to increase the prescription of anticoagulation in these patients appear warranted.