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Published on: February 26, 2013
Stroke Prevention for High-Risk Atrial Fibrillation in the Emergency Setting: The Emergency Physician Perspective
1Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Division of Emergency Medicine, the Department of Medicine, and the Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
Insights
Initiating oral anticoagulation (OAC) in the emergency department (ED) for atrial fibrillation may improve long-term use, but more research is needed to assess its safety and effectiveness compared to traditional referral. Implementation science can address barriers to ED OAC prescribing.
Area of Science:
- Cardiology
- Emergency Medicine
- Implementation Science
Background:
- Atrial fibrillation (AF) is a common emergency department (ED) presentation, with increasing visit numbers.
- Suboptimal oral anticoagulation (OAC) use in high-stroke-risk AF patients presents an opportunity for intervention.
- Current data are limited on the long-term efficacy of initiating OAC in the ED versus referral.
Purpose of the Study:
- To evaluate whether initiating OAC in the ED leads to better long-term adherence compared to referral.
- To explore the ethical and medicolegal considerations of ED-initiated chronic OAC prescribing.
- To identify barriers and potential solutions for OAC prescribing in the ED setting.
Main Methods:
- Review of existing data and literature on OAC initiation in the ED for atrial fibrillation.
- Discussion of ethical, medicolegal, and implementation science aspects of ED-based OAC prescribing.
- Consideration of specific patient populations, such as those undergoing cardioversion.
Main Results:
- Limited data exist on the comparative long-term effectiveness of ED versus non-ED OAC initiation.
- Physician reassessment is ethically and legally required for chronic medications, posing a challenge for ED-initiated OAC.
- Barriers to ED OAC prescribing include competing ED demands and lack of guaranteed follow-up.
Conclusions:
- Further research is essential to determine if OAC initiation in the ED is beneficial and safe.
- Implementation science approaches are needed to overcome barriers and support ED OAC prescribing.
- Dissemination of findings to emergency physicians is crucial if a net benefit is established.
Abstract:
Atrial fibrillation is a frequent reason for presentation to an emergency department (ED), and the number of these visits are increasing. This creates an opportunity to improve the suboptimal rate of oral anticoagulation (OAC) use in patients with atrial fibrillation who are at high risk of stroke. However, there are very few data on whether OAC initiation in the ED, compared with referral to the longitudinal health care provider to initiate it, results in better long-term use. Moreover, for ethical and medicolegal reasons, physicians who initiate a chronic medication are obliged to reassess the patient at a later date, to check for medication side effects and the need for dose adjustment. More research is needed to determine whether OAC should be prescribed in the ED, by a physician who will never see the patient again. Patients who are cardioverted in the ED might be an exception, secondary to the increased risk of stroke after cardioversion. If ED OAC prescribing is associated with better outcomes, these results must be placed into context with the care and outcomes of the other patients in the ED. If there is a net benefit, the findings should be disseminated to practicing emergency physicians, preferably via emergency physician opinion leaders. An implementation science-based approach, which addresses the barriers to ED OAC prescribing (eg, the competing demands of running an ED and lack of guaranteed follow-up care after discharge from an ED), should be used to support prescribing of OAC in the ED. Potential solutions are described.
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