43Anticoagulation strategies in patients with atrial fibrillation does our current practise result in unnecessary delays

Introduction: Anticoagulation in atrial fibrillation (AF) is strongly recommended in view of the fivefold increased risk of stroke. Current guidelines do not specify the timing of anticoagulation in patients admitted with new onset AF. There is no data comparing the effectiveness of inpatient vs. outpatient initiation of anticoagulation. Method: This was a single center, retrospective, observational study including patients admitted with new onset AF during 2013 (ICD-10 I48). We interrogated health records to identify patient characteristics, CHA2DS2VASc scores and contacted health care physicians to determine if anticoagulation was considered and the setting in which it was initiated. Results: We identified 234 patients admitted with a new diagnosis of AF (table 1). Anticoagulation was indicated in 201 patients (86%) but was considered in only 179 patients (89%) and no reason documented for the remaining 22 patients. 64 out of 179 patients had recognised contraindications. The remaining 115 patients were referred for inpatient (n=56) or outpatient anticoagulation (n=59, 32 anticoagulation clinic, 11 primary care and 16 secondary care) In the outpatient setting, only 69% were anticoagulated (29/32 anticoagulation clinic, 6/11 primary care and 6/16 secondary care). In those with (n-25) and without (n-7) scheduled anticoagulation clinic appointments on discharge, the mean delay was 6 vs. 37 days. In the primary and secondary care groups the time delay was 121 and 79 days respectively. This delay resulted in two patients, who were not anticoagulated as planned, suffering a stroke within 6 months of discharge. CHA2DS2VASc score (OR 0.72 95% 0.39-1.34, p- 0.31) or specialty team (cardiac vs. noncardiac) (OR 1.08 95% CI 0.58-2.00, p- 0.81) did not influence setting of anticoagulation. Conclusion: Anticoagulation is still not considered in all patients admitted with new onset AF. Outpatient referral for anticoagulation is associated with lack of uptake, significant delays and cerebrovascular events. Patient pathways need to be developed to minimise these delays; options include inpatient initiation, regulating clinic appointments and considering newer agents like NOACS. | | Total | Outpatient | Inpatient | | ------------------------------- | ---------- | ---------- | ---------- | | Mean Age (range) | 75 (22-99) | 77 (32-94) | 73 (45-97) | | M:F ratio | 1:1.2 | 1.1:1 | 1:1.5 | | Diabetes (%) | 57 (24) | 22 (37) | 13 (23) | | Hypertension (%) | 169 (72) | 51 (86) | 46 (82) | | Congestive heart failure (%) | 90 (39) | 24 (41) | 26 (46) | | Stroke (%) | 37 (16) | 13 (22) | 11 (20) | | Peripheral vascular disease (%) | 9 (4) | 2 (3) | 1 (2) | | Mean CHA2DS2VASc score (SD) | 3.6 (2) | 4 (2) | 3.7 (2) | | Mean hospital stay in days (SD) | 10 (11) | 8 (6) | 12 (11) | Table 1 Patients baseline characteristics