Inappropriate anticoagulation prescribing pinned to EDs

People with atrial fibrillation are eight times more likely to be prescribed oral anticoagulation inappropriately in an emergency department than in an outpatient cardiology clinic, new research reveals.

Cardiologists from the Centre for Heart Rhythm Disorders at the South Australian Health and Medical Research Institute in Adelaide say their findings show there is an urgent need to address the treatment gap by implementing oral anticoagulation prescribing protocols within emergency departments (ED) or by following up patients in a specialised AF clinic.

Published in Heart, Lung and Circulation the retrospective study involved 115 patients with a primary diagnosis of atrial fibrillation seen consecutively in the ED over a 12-month period.

Oral anticoagulation prescribing patterns were compared  to 259 consecutively managed AF patients seen in an outpatient cardiac clinic. The research team used the American Heart Association atrial fibrillation 2012 guidelines and the CHA₂DS₂-VASc score to classify whether patients had been inappropriately prescribed oral anticoagulation.

Results showed that people treated in emergency departments were  more likely to be inappropriately coagulated than those seen in an outpatient cardiac clinic (65% of patients vs 18%).  This was seen both in under-coagulation (55% of patients in the ED vs 15% for cardiac outpatients clinic) and over-coagulation (10% of patients in the ED vs 3% seen in cardiac outpatients clinic).

Over-anticoagulation occurred  most frequently with the use of antiplatelet agents such as aspirin or clopidogrel, with a smaller proportion of patients over-anticoagulated with warfarin.

These ‘missed opportunities’ for oral anticoagulation may have implications for on long-term outcomes with higher cardiovascular event rates and substantial health care burden,” the researchers wrote in a brief report in the journal.

They speculated their findings could be attributed to the acute care setting, where emergency physicians are focused on dealing with the most pressing medical issues as well as ensuring patients flow through the department.

“Reducing the missed opportunities for oral anticoagulation in the ED may prevent unnecessary thromboembolic complications and subsequent long-term sequelae in at-risk AF patients,” they wrote.

“The use of a specialised multidisciplinary AF clinic can assist in ensuring appropriate use of oral anticoagulation, in addition to other aspects of holistic AF care, and has demonstrated enhanced patient outcomes including reductions in cardiovascular mortality and hospitalisations,” they concluded.

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