title: Stroke prophylaxis in atrial fibrillation: searching for management improvement opportunities in the emergency department: the HERMES-AF study.
abstract: 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Arrhythmia Division, Spanish Society of Emergency Medicine, Madrid, Spain; Emergency Department, Unitat de Fibrillació Auricular, Hospital Clínic, Barcelona, and Grup de Recerca "Urgències: processos i patologies," IDIBAPS, Barcelona, Spain. Electronic address: bcvinent@clinic.cat.
authors.forename: Blanca
authors.initials: B
authors.lastname: Coll-Vinent
authors.affiliation: Arrhythmia Division, Spanish Society of Emergency Medicine, Madrid, Spain; Emergency Department, Hospital Universitario Severo Ochoa and University Alfonso X, Madrid, Spain.
authors.forename: Alfonso
authors.initials: A
authors.lastname: Martín
authors.affiliation: Arrhythmia Division, Spanish Society of Emergency Medicine, Madrid, Spain; Emergency Department, Hospital Universitario Torrejón, Madrid, Spain.
authors.forename: Francisco
authors.initials: F
authors.lastname: Malagón
authors.affiliation: Arrhythmia Division, Spanish Society of Emergency Medicine, Madrid, Spain; Emergency Department, Hospital Universitario Carlos Haya, Málaga, Spain.
authors.forename: Coral
authors.initials: C
authors.lastname: Suero
authors.affiliation: Arrhythmia Division, Spanish Society of Emergency Medicine, Madrid, Spain; Emergency Department, Hospital Universitario Virgen de las Nieves, Granada, Spain.
authors.forename: Juan
authors.initials: J
authors.lastname: Sánchez
authors.affiliation: Arrhythmia Division, Spanish Society of Emergency Medicine, Madrid, Spain; Emergency Department, Hospital de Basurto, Bilbao, Spain.
authors.forename: Mercedes
authors.initials: M
authors.lastname: Varona
authors.affiliation: Arrhythmia Division, Spanish Society of Emergency Medicine, Madrid, Spain; Emergency Department, Hospital Donostia, San Sebastián, Spain.
authors.forename: Manuel
authors.initials: M
authors.lastname: Cancio
authors.affiliation: Arrhythmia Division, Spanish Society of Emergency Medicine, Madrid, Spain; Emergency Department, Hospital Universitario Río Hortega, Valladolid, Spain.
authors.forename: Susana
authors.initials: S
authors.lastname: Sánchez
authors.affiliation: Sanofi-Aventis Spain, Barcelona, Spain.
authors.forename: Eugeni
authors.initials: E
authors.lastname: Montull
authors.affiliation: Arrhythmia Division, Spanish Society of Emergency Medicine, Madrid, Spain; Emergency Department, Hospital Universitario La Princesa and Universidad Autónoma, Madrid, Spain.
authors.forename: Carmen
authors.initials: C
authors.lastname: Del Arco
mesh_terms: D000367:Age Factors; D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000150:complications*; D003430:Cross-Sectional Studies; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008297:Male; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D018570:Risk Assessment; D012307:Risk Factors; D012737:Sex Factors; D013030:Spain / Q000453:epidemiology; D020521:Stroke / Q000517:prevention & control*
chemical_list: D000925:Anticoagulants