Atrial fibrillation and atrial flutter still undertreated, study shows
DENVER – Patients diagnosed with atrial flutter or atrial fibrillation in the emergency department are – more often than not – discharged without receiving prescriptions for oral anticoagulation, a linchpin for preventing strokes in this highly at-risk population, research presented here shows.
From 2010 to 2017, the prescription of these oral anticoagulants has risen from 16% of patients to 27.9% – nearly a 50% increase, but overall, 65% of patients diagnosed with flutter or fibrillation received no treatment to prevent clotting, which can lead to stroke, reported Bory Kea, MD, of Oregon Health Sciences University in Portland.
In her oral presentation at the annual scientific assembly of the American College of Emergency Physicians, Kea said, "However, there remains an opportunity to improve atrial fibrillation-flutter thromboprophylaxis as more than half of the eligible patients in 2017 were not receiving appropriate stroke prevention action within 10 days of their index visit."
"We are not doing nearly enough," she told MedPage Today, adding that treatment of women and people older than 74 is particularly lacking.
For the study, Kea and colleagues compiled information on the treatment of patients with atrial fibrillation/flutter from the emergency departments of 21 community hospitals, and included patients in the study who were newly diagnosed with non-valvular atrial fibrillation or atrial flutter and were discharged from the emergency department after being assessed as being at high risk for stroke based on a Congestive Heart Failure, Hypertension, Age, Diabetes, Previous Stroke/Transient Ischemic Attack (CHAD2DS2-VASc) score that was 2 or greater. The researchers excluded patients who had already been prescribed oral anticoagulants.
Session moderator Deborah Diercks, MD, chair of emergency medicine at the University of Texas Southwestern Medical School in Dallas, told MedPage Today: "The key here is that we are getting better at this, although we still have a long way to go. We don't know from this study what may have been the patient factors that led doctors to not prescribe oral anticoagulants. We need to learn more about that."
The primary endpoint of the study was stroke prevention action taken within 10 days – either an oral anticoagulation prescription by the emergency department or a follow-up provider, or referral of the patient to an anticoagulation management service.
"Undertreatment suggests misunderstanding of the net clinical benefit associated with oral anticoagulation in the elderly," Kea said. "I believe that most people would accept a certain level of bleeding rather than experiencing a disabling stroke. We have an opportunity to address gender and age differences to improve stroke prevention in high-risk atrial fibrillation and atrial flutter."
The study looked at a total of 10,281 patients over the 2010-2017 period, and found that 75% of those patients did not receive any action to reduce their risk of stroke after finding they were high risk due to atrial fibrillation and atrial flutter, Kea reported.
The average age of the participants in the study was 73.7, and 61.1% of the population studied were women; 82% identified as white, 7.2% as Asian, 4.5% as black, and 7.6% as having Hispanic ethnicity.
Women were 21% less likely to receive oral anticoagulants after being diagnosed with atrial fibrillation or atrial flutter (aOR 0.79, 95% CI 0.71-0.88) and people age 75 or older were 41% less likely to receive oral anticoagulation for their condition (aOR 0.59, 95% CI 0.45-0.76). However, compared with the results for 2010, patients in 2017 were more than twice as likely to receive the medications (aOR 2.60, 95% CI 2.08-3.24), the researchers found.
Study limitations, Kea said, included that only patients who were members of the Kaiser Permanente Northern California system who had prescription coverage were included in the study, and that there was a possibility of incorrect classification of atrial fibrillation or atrial flutter, since the diagnoses were based on hospital codes for the conditions. There was also limited clinical data that could be extracted from claims information.
Kea disclosed relevant relationships with Ortho-Clinical Diagnostics.
Dierks disclosed no relevant relationships with industry.
American College of Emergency Physicians
Source Reference: Kea B, et al "Appropriate Stroke Prophylaxis Action After US Emergency Department Diagnosis and Discharge of Atrial Fibrillation and Flutter Patients" ACEP 2019, Abstract 96.
Read the original article on Medpage Today: ER Docs Not Big on Stroke Prevention Meds