Prescribing OACs in the ED increases long-term use by 30%
Patients with atrial fibrillation may be more likely to stick to a regimen of oral anticoagulation if they’re first prescribed OACs in the emergency department, according to a study published Dec. 9 in the Canadian Medical Association Journal.
First author Clare L. Atzema, MD, MSc, of ICES Central, and colleagues explained in CMAJ that in Ontario, where they based their study, hospitals log around 20,000 emergency department visits for AFib each year. The arrhythmia is associated with a five-fold increased risk of stroke—for which one-year mortality is just 50%—and although stroke prevention with OACs can cut the risk of an event by 60%, oral anticoagulation is underused in the AFib population.
“The advent of direct oral anticoagulants, which do not require bridging or monitoring of the international normalized ratio, may improve the willingness of emergency physicians to initiate a long-term medication that may cause bleeding,” Atzema et al. wrote. “However, current usual care is referral to the longitudinal care provider to initiate such medications, as that provider will have the patient’s complete medical history, can follow the patient for potential adverse effects and dose adjustments and has more time for shared decision-making, possibly over more than one visit.”
Atzema and her team assessed the long-term use of OACs in 2,132 AFib patients who were either prescribed the drugs in the emergency department or by their primary care physician. All patients, drawn from 15 hospitals across Ontario, presented to an ED between 2009 and 2014 with a primary diagnosis of AFib, were discharged home and were eligible for and willing to take stroke-prevention therapies.
The researchers found that 402 patients in the study—18.9%—received a prescription for an OAC in the emergency department. After weighting, 67.8% of those patients met the study’s primary endpoint of filling a prescription for an OAC six months after their index hospitalization. Just 37.2% of patients who didn’t receive a prescription in the ED filled a script six months later.
The data revealed an absolute risk increase of 30.6% and a number needed to treat (NNT) of 3 for patients prescribed OACs in the emergency department, suggesting initiating the therapies earlier increased people’s long-term use by nearly one-third.
“The NNT had increased to 4 by one year, which was expected because persistence with this therapy is known to decline over time,” Atzema et al. wrote. “To prevent one stroke at one year, the NNT with OACs is 1.7; therefore, the NNT for oral anticoagulant prescriptions in the emergency department to prevent a stroke is about 7. By comparison, the NNT for statins to prevent nonfatal MI in patients with a history of heart disease is 39.”
The team said their work might encourage physicians working in the ED to consider initiating OACs in AFib patients who are being discharged home rather than waiting for their primary provider to make the move, since the former approach resulted in better stroke prevention.
After graduating from Indiana University-Bloomington with a bachelor’s in journalism, Anicka joined TriMed’s Chicago team in 2017 covering cardiology. Close to her heart is long-form journalism, Pilot G-2 pens, dark chocolate and her dog Harper Lee.