Atrial fibrillation and atrial flutter (AF/AFL) are associated with an increased   risk of stroke and systemic embolism. However, many patients are not started   on guideline-recommended oral anticoagulation (OAC). We determined factors   associated with initiation of OAC in eligible patients presenting to   emergency departments. This retrospective cohort included patients with   electrocardiogram (ECG)-documented AF/AFL presenting to 4 urban emergency   departments in 2015. Presenting diagnoses, admission status, and   comorbidities were determined by chart review. The primary outcome was OAC   prescription within 90 days of ED presentation in guideline-eligible patients   not previously on OAC. Of 4948 patients presenting to emergency departments   with ECG-documented AF/AFL, we identified 2059 patients with Congestive Heart   failure, Age (≥65),Diabetes, and Stroke (CHADS-65) score ≥1 not previously on   OAC. Of those patients, 1287 (62.5%) were admitted, and 772 (37.5%) were   discharged from the emergency department. Within 90 days of discharge, 663   (32.2%) patients were initiated on OAC. On multivariable analysis,   hospitalization (odds ratio [OR] 1.31; 95% confidence interval [CI]   1.05-1.63, P = 0.02), presenting diagnosis of AF/AFL (OR 4.56, 95% CI   3.60-5.79, P < 0.01), and higher CHADS-65 score (OR 1.14 per point, 95% CI   1.04-1.25, P < 0.01) were associated with increased rates of OAC   initiation. However, there was no association with individual components of   the CHADS-65 score. Guideline-directed OAC is infrequently initiated in   eligible patients within 90 days of presenting to emergency departments. The   strongest factors associated with OAC initiation rates were hospitalization   or having primary presenting diagnoses in emergency departments of AF/AFL   after adjusting for other important characteristics. New interventions are   required to improve appropriate OAC initiation in patients with AF/AFL.

Authors: Robert J H Miller, Derek S Chew, Saman Rezazadeh, Sheila Klassen, Payam Pournazari, Eddy Lang, F Russell Quinn