Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada.
Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada.
Can J Cardiol. 2018 Jun;34(6):804-807. doi: 10.1016/j.cjca.2018.03.009. Epub 2018 Mar 24.
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.
心房颤动和心房扑动（AF/AFL）与中风和全身性栓塞的风险增加有关。然而，许多患者并未开始接受指南推荐的口服抗凝治疗（OAC）。我们确定了在符合条件的急诊科就诊的患者中开始 OAC 的相关因素。这项回顾性队列研究纳入了 2015 年在 4 个城市急诊科就诊的心电图（ECG）记录的 AF/AFL 患者。通过病历回顾确定就诊诊断、入院状态和合并症。主要结局是在没有接受 OAC 的指南合格患者中，在急诊科就诊后 90 天内开始使用 OAC。在因心电图记录的 AF/AFL 而就诊急诊科的 4948 名患者中，我们确定了 2059 名未接受 OAC 治疗且 CHADS-65 评分≥1 的充血性心力衰竭、年龄（≥65 岁）、糖尿病和中风患者。这些患者中，1287 人（62.5%）住院，772 人（37.5%）从急诊科出院。出院后 90 天内，有 663 名患者开始接受 OAC。多变量分析显示，住院治疗（比值比[OR]1.31；95%置信区间[CI]1.05-1.63，P=0.02）、AF/AFL 的就诊诊断（OR 4.56，95%CI 3.60-5.79，P<0.01）和更高的 CHADS-65 评分（OR 每点 1.14，95%CI 1.04-1.25，P<0.01）与 OAC 开始率的增加相关。然而，CHADS-65 评分的各个组成部分与 OAC 起始率无关。在急诊科就诊后 90 天内，指南指导的 OAC 很少在符合条件的患者中开始。在调整其他重要特征后，与 OAC 起始率最相关的因素是住院治疗或在急诊科以 AF/AFL 为主要就诊诊断。需要新的干预措施来改善 AF/AFL 患者的适当 OAC 起始治疗。
