Incident atrial fibrillation in the emergency department in Ontario: a population-based retrospective cohort study of follow-up care

Atzema, Clare; Yu, Bing; Ivers, Noah; Rochon, Paula A.; Lee, Douglas S.; Schull, Michael J.; Austin, Peter C.

doi:10.9778/cmajo.20140099

Cited by 13 publications

(4 citation statements)

References 37 publications

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“…They also identified underuse of oral anticoagulants by emergency physicians. 34 In another retrospective study, Atzema et al 35 noted the low physician follow-up rate within 7 days of an ED visit. None of these studies attempted to identify risk factors for adverse events.…”

Section: Discussionmentioning

confidence: 99%

Outcomes for Emergency Department Patients With Recent-Onset Atrial Fibrillation and Flutter Treated in Canadian Hospitals

Stiell

Clement

Rowe

et al. 2017

Annals of Emergency Medicine

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Although most recent-onset atrial fibrillation and flutter patients were treated aggressively in the ED, there were few 30-day serious outcomes. Physicians underprescribed oral anticoagulants. Potential risk factors for adverse events include longer duration from arrhythmia onset, previous stroke or transient ischemic attack, pulmonary congestion on chest radiograph, and not being in sinus rhythm at discharge. An ED strategy of sinus rhythm restoration and discharge in most patients is effective and safe.

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Section: Discussionmentioning

confidence: 99%

Outcomes for Emergency Department Patients With Recent-Onset Atrial Fibrillation and Flutter Treated in Canadian Hospitals

Stiell

Clement

Rowe

et al. 2017

Annals of Emergency Medicine

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“…Prior work has demonstrated that patients who are diagnosed with AF in the ED are more likely to receive follow‐up if an established family physician is identified. 42 A major factor in adherence is physician communication and patient understanding of OACs. 43 More research is needed to better understand how both may serve as potential barriers to adherence and to help develop mitigating strategies.…”

Section: Discussionmentioning

confidence: 99%

“… 43 More research is needed to better understand how both may serve as potential barriers to adherence and to help develop mitigating strategies. 42 Patient health literacy, which is associated with medication adherence, disease status, and outcomes, 44 , 45 should be assessed in each patient. 46 Further studies, including randomized controlled trials, are needed to determine whether provision of educational material on the importance of OAC adherence tailored to patient‐specific health literacy can improve adherence.…”

Section: Discussionmentioning

confidence: 99%

Trends in Uptake and Adherence to Oral Anticoagulation for Patients With Incident Atrial Fibrillation at High Stroke Risk Across Health Care Settings

Yogasundaram

Dover

Hawkins

et al. 2022

JAHA

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Background Oral anticoagulation (OAC) therapy prevents morbidity and mortality in nonvalvular atrial fibrillation; whether location of diagnosis influences OAC uptake or adherence is unknown. Methods and Results Retrospective cohort study (2008–2019), identifying adults with incident nonvalvular atrial fibrillation across health care settings (emergency department, hospital, outpatient) at high risk of stroke. OAC uptake and adherence via proportion of days covered for direct OACs and time in therapeutic range for warfarin were measured. Proportion of days covered was categorized as low (0–39%), intermediate (40–79%), and high (80–100%). Warfarin control was defined as time in therapeutic range ≥65%. All‐cause mortality was examined at a 3‐year landmark. Among 75 389 patients with nonvalvular atrial fibrillation (47.0% women, mean 77.4 years), 19.7% were diagnosed in the emergency department, 59.1% in the hospital, and 21.2% in the outpatient setting. Ninety‐day OAC uptake was 51.6% in the emergency department, 50.9% in the hospital, and 67.9% in the outpatient setting ( P <0.0001). High direct OAC adherence increased from 64.9% to 80.3% in the emergency department, 64.3% to 81.7% in the hospital, and 70.9% to 88.6% in the outpatient setting over time ( P values for trend <0.0001). Warfarin control was 40.3% overall and remained unchanged. In multivariable analysis, outpatient diagnosis compared with the hospital was associated with greater OAC uptake (odds ratio [OR], 1.79; [95% CI, 1.72–1.87]) and direct OAC (OR, 1.42; [95% CI, 1.27–1.59]) and warfarin (OR, 1.49; [95% CI, 1.36–1.63]) adherence. Varying or persistently low adherence was associated with a poor prognosis, especially for warfarin. Conclusions Locale of nonvalvular atrial fibrillation diagnosis is associated with varying OAC uptake and adherence. Interventions specific to health care settings are needed to improve stroke prevention.

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“…Using patients who were alive at the time of outcome assessment (to avoid immortal time bias 36 ), we estimated a propensity score by regressing prescription provision on 29 variables selected a priori. 15,27,37 This method weights participants by the inverse of the probability of actual treatment received. 38 Balance between groups was assessed using weighted standardized differences.…”

Section: Discussionmentioning

confidence: 99%

Prescribing of oral anticoagulants in the emergency department and subsequent long-term use by older adults with atrial fibrillation

Atzema

Jackevicius

Chong

et al. 2019

CMAJ

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M ore than 33 million people have atrial fibrillation worldwide, 1 and the prevalence is expected to double in the coming decades. 2,3 Atrial fibrillation is associated with a fivefold increase in the risk of stroke, 4,5 for which the 1-year mortality rate is 50%. 6 Stroke prevention with oral anticoagulation therapy decreases the risk by about 60%, 7,8 and numerous guidelines endorse this type of therapy for high-risk patients with atrial fibrillation. 9-11 Nonetheless, many studies have documented suboptimal use of oral anticoagulants. [12][13][14] Patients with atrial fibrillation often present to the emergency department because of symptoms such as palpitations, shortness of breath and chest pain. 15,16 In Ontario, there are about 20 000 emergency department visits per year for atrial fibrillation, and most of these patients (63%) are sent home after emergency care (v. 31% in the United States). 17 Therefore, the emergency department may be an important setting for improvement of suboptimal prescribing rates for oral anticoagulants. [18][19][20] The advent of direct oral anticoagu lants, 21-24 which do not require bridging or monitoring of the international normalized ratio, may improve the willingness of emergency physicians to initiate a long-term medication that may cause bleeding. However, current usual care is referral to the longitudinal care provider (e.g., primary care provider or cardiologist) to initiate such medications, as that provider will have the patient's complete medical history, can follow the patient for potential adverse effects and dose adjustments, and has more time for shared decision-making, possibly over more than 1 visit. 25,26 In addition, there are limited data on whether initiation of oral anticoagulants in the emergency department results in greater long-term use. 27 We assessed the long-term use of oral anticoagulants after provision of a prescription in the emergency department, compared with deferral to the longitudinal health care provider for initiation of therapy.

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Incident atrial fibrillation in the emergency department in Ontario: a population-based retrospective cohort study of follow-up care

Cited by 13 publications

References 37 publications

Outcomes for Emergency Department Patients With Recent-Onset Atrial Fibrillation and Flutter Treated in Canadian Hospitals

Outcomes for Emergency Department Patients With Recent-Onset Atrial Fibrillation and Flutter Treated in Canadian Hospitals

Trends in Uptake and Adherence to Oral Anticoagulation for Patients With Incident Atrial Fibrillation at High Stroke Risk Across Health Care Settings

Prescribing of oral anticoagulants in the emergency department and subsequent long-term use by older adults with atrial fibrillation

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