title: Missed opportunities for appropriate anticoagulation among emergency department patients with uncomplicated atrial fibrillation or flutter.
abstract: OBJECTIVE
  Emergency department (ED) patients with atrial fibrillation or flutter are at risk of stroke, and guidelines recommend anticoagulation for patients with increased cardiovascular risk. Emergency physicians have a unique opportunity to provide appropriate anticoagulation for such patients, and we wished to investigate whether this was accomplished.
  
  
  METHODS
  This retrospective cohort study used a database from 2 urban EDs to identify consecutive patients with an ED discharge diagnosis of atrial fibrillation or flutter from April 1, 2006, to March 31, 2010, who were managed solely by the emergency physician. Comorbidities, rhythms, and management were obtained by chart review, and complicated patients (those with an acute underlying medical condition) were excluded by predefined criteria. Patient medications on ED presentations were obtained through the provincial Pharmanet database. Patients were stratified into CHADS 2 (congestive heart failure, hypertension, age > 75, diabetes, stroke/transient ischemic attack) scores, and the primary outcome was the proportion of higher-risk (CHADS 2 score >0) patients who were discharged home with the incorrect anticoagulation by the emergency physician. The secondary outcome was the number of lower-risk (CHADS 2=0) patients who began receiving warfarin by the emergency physician orders. The regional ED database was interrogated to ascertain the number of patients who had a stroke at 30 days.
  
  
  RESULTS
  Consecutive patients (1,090) were enrolled and 732 were discharged home with no cardiology consultation (657 fibrillation and 75 flutter). Of 151 higher-risk (CHADS 2 score >0) patients who should have been anticoagulated, 80 (53.0%; 95% confidence interval 44.7% to 61.0%) were discharged home from the ED without appropriate anticoagulation. In this group, 1 patient had an ischemic stroke at 24 days. Among 300 lower-risk patients (CHADS 2 score=0), 25 (8.3%; 95% confidence interval 5.6% to 12.2%) had warfarin initiated.
  
  
  CONCLUSIONS
  In this cohort of ED patients with uncomplicated atrial fibrillation or flutter who were discharged without cardiology involvement, many were not appropriately anticoagulated before ED arrival, and more than half of such patients did not appear to have corrective measures initiated by the emergency physician. This may represent a potential opportunity to improve patient care and outcomes.
authors.affiliation: Department of Emergency Medicine, St Paul's Hospital and the University of British Columbia, Vancouver, British Columbia, Canada. Electronic address: frank.scheuermeyer@gmail.com.
authors.forename: Frank X
authors.initials: FX
authors.lastname: Scheuermeyer
authors.forename: Grant
authors.initials: G
authors.lastname: Innes
authors.forename: Reza
authors.initials: R
authors.lastname: Pourvali
authors.forename: Chris
authors.initials: C
authors.lastname: Dewitt
authors.forename: Eric
authors.initials: E
authors.lastname: Grafstein
authors.forename: Claire
authors.initials: C
authors.lastname: Heslop
authors.forename: Jan
authors.initials: J
authors.lastname: MacPhee
authors.forename: John
authors.initials: J
authors.lastname: Ward
authors.forename: Brett
authors.initials: B
authors.lastname: Heilbron
authors.forename: Lorraine
authors.initials: L
authors.lastname: McGrath
authors.forename: Jim
authors.initials: J
authors.lastname: Christenson
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000150:complications* / Q000628:therapy; D001282:Atrial Flutter / Q000150:complications* / Q000628:therapy; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D020521:Stroke / Q000517:prevention & control; D014859:Warfarin / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D014859:Warfarin