1. Stroke Prophylaxis in Atrial Fibrillation: Searching for Management Improvement Opportunities in the Emergency Department: The HERMES-AF Study
- Author
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Blanca Coll-Vinent, Alfonso Martín, Francisco Malagón, Coral Suero, Juan Sánchez, Mercedes Varona, Manuel Cancio, Susana Sánchez, Eugeni Montull, Carmen del Arco, Emilio Román, Francisca Heredia, Ana Ma Sagarra, Ángel Estella, Francisco Manuel Brun, Elías Simón, José Manuel Torres, Elisa Lopera, Fuensanta Soriano, Fernando Santamarina, Matilde F. Feixas, F. Javier Hierro, José Ma Santos, Álvaro F. Perea, Francisco Tembury, Macarena Rizo, Adolfo Ramirez, Rafael Sindiones, Francisco Moya, Amparo Fernández, Francisco Ruiz, José Manuel Garrido, Enrique Almagro, Javier Povar, Elisa Aldea, Miguel Rivas, Fernando Galve, Manuel Muñoz, Juan Alberto García, Pedro Cals, Ana Gutierrez, Luis García-Castrillo, María José Rodriguez, Fernando Richard, Beatriz López, Luis Lapuerta, Tomás Toranzo, Nicanor Zapico, Ana Melendre, José Aguilar, Ma del Mar Sousa, Alberto Lopez, Luis Montero, Raimundo Rodriguez-Bobada, Ramón Perales, Rosa Roldán, Carolina Fuenzalida, Olga Ma Trejo, Alfons Aguirre, Teresa Soriano, Mireia Vila, Lluis Fornet, Francisco Casarramona, Ma Isabel Sánchez, Julio Font, Joan Espinach, Mercè Almirall, Joaquin Danés, Alvaro Herrera, Silvia Flores, Ali Jammoul, José Vicente, Ma Isabel Campos, Rafael Colomina, Joaquin Escámez, Begoña Arcos, Ma Carmen Navarro, Javier Millán, Jose Javier Noceda, Salvador Rubini, Ricardo Rubini, José Carbajosa, Ma Elena Díaz, Francisco J. Navarro, Matilde González, Adelaida Mateo, Cristina Gisbert, Francisco Navarro, Ignacio López, Francisco David Muñoz, Ma Teresa García, Pablo Lamas, Luis Amador, Ricardo Calvo, Carmen Seijas, Ma C. Selloso, Manuel García, Francisco José Aramburu, Ma A. Leciñena, Alex Planas, Ignacio Ayala, Jose Emilio Alonso, Benito Gutiérrez, Pedro Marco, Belén Rodríguez, Juan Manuel Parra, Juan González, Luis Diaz, Oscar Álvarez, Juan Andueza, Joaquin García, Gregorio Jiménez, Manuel Ruizy, Esther Mora, Juan Torres, Jesús Canora, Carlos Bibiano, Pascual Piñera, Enrique Retuerto, Jose Ma Melgares, Jesús Cruzado, Carmen Escudero, Ángel Hernández, Eduardo Jiménez, and Jose López
- Subjects
Male ,medicine.medical_specialty ,Cross-sectional study ,Risk Assessment ,Sex Factors ,Risk Factors ,Internal medicine ,Atrial Fibrillation ,Humans ,Medicine ,Practice Patterns, Physicians' ,Medical prescription ,Intensive care medicine ,Stroke ,Aged ,business.industry ,Age Factors ,Anticoagulants ,Atrial fibrillation ,Odds ratio ,Emergency department ,medicine.disease ,Cross-Sectional Studies ,Spain ,Heart failure ,Emergency Medicine ,Female ,Emergency Service, Hospital ,business ,Risk assessment - Abstract
Study objective We determine the prevalence of stroke prophylaxis prescription in emergency department (ED) patients with atrial fibrillation and the factors associated with a lack of prescription of anticoagulation in high-risk patients without contraindications. Methods This was a multicenter, observational, cross-sectional study with prospective standardized data collection carried out in 124 Spanish EDs. Clinical variables, risk factors for stroke, type of prophylaxis prescribed, and reasons for not prescribing anticoagulation in high-risk patients (congestive heart failure/left ventricular dysfunction, hypertension, age >75 years, diabetes and previous stroke/transient ischemic attack/systemic embolism [CHADS2] score ≥2 and the congestive heart failure/left ventricular dysfunction, hypertension, age >75 years, diabetes, previous stroke/transient ischemic attack/systemic embolism, vascular disease age 65 to 74 years and sex category [CHA2DS2-VASc] score ≥2) without contraindications were collected. Results Of 3,276 patients enrolled, 71.5% were at high risk according to CHADS2; 89.7% according to CHA2DS2-VASc. At discharge from the ED, 2,255 patients (68.8%) were receiving anticoagulants, 1,691 of whom (75%) were high-risk patients. Of the 1,931 patients discharged home, anticoagulation was prescribed for 384 patients (19.9%) de novo and for 932 patients (48.3%) previously receiving anticoagulation. The main reasons for not prescribing anticoagulation to eligible patients were considering antiplatelet therapy as adequate prophylaxis (33.1%), advanced age (15%), and considering stroke risk as low (8.3%). Advanced age (odds ratio 0.46; 95% confidence interval 0.30 to 0.69) and female sex (odds ratio 0.50; 95% confidence interval 0.36 to 0.71) were significantly associated with the lack of prescription of anticoagulation to eligible patients. Conclusion In Spain, most patients with atrial fibrillation treated in EDs who do not receive anticoagulation are at high risk of stroke, with relevant differences with regard to the risk stratification scheme used. Anticoagulation is underused, mainly because the risk of stroke is underestimated by the treating physicians and the benefits of antiplatelets are overrated, principally in female patients and the elderly. Efforts to increase the prescription of anticoagulation in these patients appear warranted.
- Published
- 2015
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