Heartbeats and Headaches: Are We Doing Enough to Prevent Strokes After an ER Visit for AFib?

Hey there, everyone! Let’s chat about something that’s pretty close to, well, the heart, and definitely crucial for our brains: atrial fibrillation (or AFib for short) and how we’re handling it in the hustle and bustle of our emergency departments (EDs). You know, AFib is that pesky irregular heartbeat that can, unfortunately, really ramp up the risk of having a stroke. We’re talking a five-fold increase! Scary stuff, right?

Now, we’ve got some good tools in our medical arsenal, specifically oral anticoagulants (OACs), which are basically blood thinners. These medications are champs at reducing the risk of those nasty AFib-related blood clots that can lead to strokes. Global guidelines are all in agreement: if a patient is a good candidate, getting them on OACs 외부사이트로 연결됩니다. in a timely manner is super important. But here’s the kicker: “real-life” data often shows a bit of a disconnect. It seems like up to two-thirds of eligible outpatients with AFib who are at risk aren’t actually getting these OAC prescriptions. Yikes!

The ER: A Critical Starting Point?

Think about it – over half a million folks show up in U.S. EDs each year because of acute AFib, and for more than a quarter of all new AFib diagnoses, the ED is where it all begins. This makes the ED a really pivotal, and perhaps overlooked, spot to get the ball rolling on proper stroke prevention. With the newer direct OACs (DOACs) being easier to manage, you’d think it’d be a golden opportunity, right?

So, a group of researchers, myself included in spirit as I delve into their work, wanted to get a better handle on what’s actually happening. We looked into stroke prevention actions for patients with AFib who are at high risk for stroke, right after they’re discharged from the ED. We also wanted to see if things like patient characteristics, doctor characteristics, or even hospital features played a role.

This was a pretty hefty retrospective look, covering 21 community medical centers in Northern California over an 8-year stretch (from 2010 to 2017). We focused on adult patients who:

• Had a primary diagnosis of non-valvular AFib (meaning their AFib wasn’t caused by a heart valve problem).
• Were at high risk for stroke, based on a score called CHA2DS2-VASc (score of 2 or more).
• Had a low to intermediate risk of bleeding, using another score called HAS-BLED (score less than 4) – because, you know, blood thinners have their own risks.
• Weren’t already on OACs recently (in the last 90 days).
• Were discharged home from the ED.

Our main goal was to see how often an “OAC Action” occurred within 14 days of the ED visit. An OAC Action meant either getting an OAC prescription (we used filled prescriptions as a proxy) or having a consultation with an anticoagulation management service (AMS) – these are often pharmacist-led services that are fantastic for patient education and monitoring.

What Did We Find? Some Good News, Some “Hmm” News

Out of a massive pool of almost 320,000 adult health plan members with an ED diagnosis of AFib, we zeroed in on 9,603 eligible ED discharges. The average age was around 73, and a little over 62% were female. The average CHA2DS2-VASc score was 3.5, indicating a solid risk for stroke.

So, the good news first: Over the study period, from 2010 to 2017, the rate of OAC Action did go up! It climbed from 21.0% to 33.5%. That’s a positive trend, showing we’re getting better. When we dug deeper, we found that the actual rate of ED doctors prescribing OACs at discharge was still pretty low, though it did inch up from 2.4% in 2010 to 6.0% in 2017. Most of the “OAC Action” was happening in the 14 days after discharge, likely through follow-up.

Now for the “hmm” parts. When we crunched the numbers, some disparities popped out. After adjusting for a bunch of factors, we saw that:

• Female patients were about 3.6% less likely to receive an OAC Action compared to male patients. This echoes other big studies and really makes you think about potential biases.
• Older patients, specifically those aged 85 and above, were about 3.8% less likely to get OAC Action compared to those younger than 64.
• Interestingly, patients with a CHA2DS2-VASc score of 4-5 (a higher stroke risk) were actually more likely (by 4.5%) to get OAC Action than those with a score of 2-3. But, and this is a bit of a head-scratcher, patients in the highest risk category (CHA2DS2-VASc score of 6-9) didn’t see a higher rate of OAC Action compared to the 2-3 score group.
• Hospital size seemed to matter a bit too, with larger EDs (more beds) having slightly lower rates of OAC Action compared to the smallest ones (fewer than 20 beds).
• On a positive note for specific groups, patients of Hispanic ethnicity had higher rates of OAC Action (5.5% higher). While Black/African American and Asian patients also had higher rates than non-Hispanic Whites, these differences weren’t statistically significant or were borderline.
• When looking at physician characteristics, Asian physicians were about 4.5% more likely to take OAC Action than physicians of other races/ethnicities. Patient-physician race or language concordance didn’t seem to be a major driver overall, though.

Why These Gaps? And What Can We Do?

It’s a bit concerning to see these gaps, especially for women. It really highlights the need for ongoing discussions and training around implicit bias in healthcare. We want to make sure everyone gets the care they need, based on evidence, not on unconscious assumptions.

The age thing is a bit more nuanced. For very elderly patients, the net clinical benefit of OACs can sometimes decrease because other risks, like major bleeding or death from other causes, start to weigh more heavily. So, while guidelines might point one way, experienced clinicians might be intuitively weighing these complex factors, especially for those over 85. The study did find that patients aged 75-84 actually had a higher rate of OAC action initially, but this effect disappeared in the adjusted model when comparing those over 85 to much younger patients.

The finding about the highest stroke risk group (CHA2DS2-VASc 6-9) not getting more OACs is also intriguing. It’s possible that these patients have a lot of other health issues (co-morbidities) that make the decision to start anticoagulants more complex. They might be frailer, or perhaps their care involved more specialist consultations (like cardiology or palliative care) that led to a different, individualized plan not captured simply by OAC prescription rates.

It’s also worth noting that the study period saw the introduction and increased use of DOACs. Dabigatran hit the system’s formulary in 2014, and apixaban in 2016. The upward trend in OAC prescribing seems to correlate with these medications becoming more available. This makes sense – DOACs are generally easier to manage than older anticoagulants like warfarin (no frequent blood tests!), so their availability likely made docs more comfortable prescribing them, especially from a busy ED setting.

So, what’s the game plan to bridge these gaps?

• Cost and Access: Making DOACs more affordable and improving insurance coverage nationwide could be a huge help. If patients can’t afford the meds, a prescription doesn’t do much good.
• Support Systems: Anticoagulation Management Services (AMS) are fantastic resources. Enlisting their help more consistently can make a big difference.
• Smart Tech: Clinical Decision Support (CDS) tools embedded in electronic health records could be a game-changer. Imagine a tool that automatically calculates the CHA2DS2-VASc score and flags eligible patients for OACs right when the ED doc is seeing them. This could help minimize bias and ensure guidelines are consistently applied. In fact, the research team behind this study actually designed and trialed such a tool, and guess what? During the intervention phase with the CDS tool, the gender difference in OAC initiation disappeared! How cool is that?

A Few Caveats, As Always

Like any study, this one has its limitations. It was done within an integrated health system with good access to primary care, so the gaps we saw might actually be even wider in other settings. Also, we used filled prescriptions as a stand-in for actual prescribing – so, some docs might have written scripts that patients never filled. And, we couldn’t dig into every single patient-level detail (like fall risk or patient preferences) that might have swayed a doctor’s decision.

The guidelines for AFib care also evolved, especially around 2023, to include the duration of AFib as a factor. This study ended in 2017, so it reflects practices before these newer nuances. Future research will need to keep exploring if these risk scores (CHA2DS2-VASc and HAS-BLED) are perfectly suited for the acute care ED population, especially with evolving guidelines.

The Bottom Line

While we’re making strides in getting high-risk AFib patients the stroke prevention they need after an ED visit, there’s still room for improvement. We really need to focus on addressing those disparities, especially for women and very elderly patients, ensuring that decisions are evidence-based and equitable. The ED is a critical touchpoint, and by leveraging smart tools and a continued focus on education and awareness, we can hopefully turn more of those “missed opportunities” into life-saving interventions. It’s all about keeping those hearts beating strong and those minds sharp!

Source: Springer