The Use of Oral Anticoagulants in Patients with Atrial Fibrillation in the Emergency Department

Background and aim: Atrial Fibrillation is the leading cause of embolic stroke, yet less than half of high-risk patients with atrial fibrillation are on adequate stroke prevention with oral anticoagulants. Guidelines for the primary prevention of stroke recognize the emergency department as a location for physicians to identify atrial fibrillation and initiate anticoagulants. We sought to compare anticoagulant prescription rates in patients with atrial fibrillation in various provider settings to identify opportunities for improvement in cardioembolic stroke prevention. Methods: A retrospective cohort study of 436 patients with atrial fibrillation presenting to the emergency department from 2014 to 2018 was performed. Baseline characteristics, stroke risk, and rates of anticoagulant prescription were compared across 3 groups: (1) patients discharged from the emergency department, (2) patients admitted under observation status, and (3) patients admitted to inpatient hospital service. Results: Among 436 patients (47% women, 51% Hispanic), we identified 105 in the emergency department cohort, 131 in the observation cohort and 200 in the inpatient cohort. The average CHA(2)DS(2)-VASc score was 2.5 in the emergency department cohort, 2.6 in the observation cohort and 3.3 in the inpatient cohort. Anticoagulants were prescribed for high-risk patients (CHA(2)DS(2)-VASc score > 2) in 17.5% (7/40) of the emergency department cohort compared to 73% (38/52, P< .0001) of the observation cohort and 80% (82/103 P< .0001) of the inpatient cohort. Conclusion: Patients with atrial fibrillation are more likely to be prescribed anticoagulants if admitted to inpatient or under observation status compared to the emergency department.