title: Use of Oral Anticoagulant Therapy in Older Adults with Atrial Fibrillation After Acute Ischemic Stroke.
abstract: OBJECTIVE
  To explore barriers to anticoagulation in older adults with atrial fibrillation (AF) at high risk of stroke and to identify opportunities for interventions that might increase use of oral anticoagulants (OACs).
  
  
  METHODS
  Retrospective cohort study.
  
  
  METHODS
  Two large community-based AF cohorts.
  
  
  METHODS
  Individuals with ischemic stroke surviving hospitalization (N = 1,405, mean age 79).
  
  
  METHODS
  Using structured chart review, reasons for nonuse of OAC were identified, and 1-year poststroke survival was assessed. Logistic regression was used to identify correlates of OAC nonuse.
  
  
  RESULTS
  Median CHA2DS2-VASc score was 5, yet 44% of participants were not prescribed an OAC at discharge. The most-frequent (nonmutually exclusive) physician reasons for not prescribing OAC included fall risk (26.7%), poor prognosis (19.3%), bleeding history (17.1%), participant or family refusal (14.9%), older age (11.0%), and dementia (9.4%). Older age (odds ratio (OR) = 8.96, 95% confidence interval (CI) = 5.01-16.04 for aged ≥85 vs <65) and disability (OR = 12.58, 95% CI = 5.82-27.21 for severe vs no deficit) were the most-important independent predictors of nonuse of OACs. By 1 year, 42.5% of those not receiving an OAC at discharge had died, versus 19.1% of those receiving an OAC (P < .001), far higher than recurrent stroke rates.
  
  
  CONCLUSIONS
  Despite very high stroke risk, more than 40% of participants were not discharged with an OAC. Dominant reasons included fall risk, poor prognosis, older age, and dementia. These individuals' high 1-year mortality rate confirmed their high level of comorbidity. To improve anticoagulation decisions and outcomes in this population, future research should focus on strategies to mitigate fall risk, improve assessment of risks and benefits of anticoagulation in individuals with AF, and determine whether newer anticoagulants are safer in complex elderly and frail individuals.
authors.affiliation: Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts.|Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts.|Harvard Medical School, Boston, Massachusetts.
authors.forename: Emer R
authors.initials: ER
authors.lastname: McGrath
authors.affiliation: Division of Research, Kaiser Permanente of Northern California, Oakland, California.|Department of Medicine, Epidemiology and Biostatistics, University of California, San Francisco, California.|Departments of Health Research and Policy, Stanford University School of Medicine, Stanford, California.
authors.forename: Alan S
authors.initials: AS
authors.lastname: Go
authors.affiliation: Harvard Medical School, Boston, Massachusetts.|Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Yuchiao
authors.initials: Y
authors.lastname: Chang
authors.affiliation: Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Leila H
authors.initials: LH
authors.lastname: Borowsky
authors.affiliation: Division of Hospital Medicine, University of California, San Francisco, California.
authors.forename: Margaret C
authors.initials: MC
authors.lastname: Fang
authors.affiliation: Department of Research and Evaluation, Kaiser Permanente of Southern California, Pasadena, California.
authors.forename: Kristi
authors.initials: K
authors.lastname: Reynolds
authors.affiliation: Harvard Medical School, Boston, Massachusetts.|Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Daniel E
authors.initials: DE
authors.lastname: Singer
mesh_terms: D000058:Accidental Falls; D000284:Administration, Oral; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000188:drug therapy* / Q000401:mortality; D015331:Cohort Studies; D015897:Comorbidity; D003704:Dementia / Q000150:complications; D011307:Drug Prescriptions / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D010351:Patient Discharge; D011379:Prognosis; D012008:Recurrence; D012189:Retrospective Studies; D020521:Stroke / Q000517:prevention & control*
chemical_list: D000925:Anticoagulants
keywords: atrial fibrillation; decision-making; ischemic stroke; oral anticoagulants