Stroke prophylaxis in atrial fibrillation: searching for management improvement opportunities in the emergency department: the HERMES-AF study.

Blanca Collvinent,Alfonso Martin,Francisco Malagon,Coral Suero,Juan Ignacio Moreno Sanchez,M A Varona,Manuel Cancio,Susana M Sanchez,Eugeni Montull,Carmen Del Arco, E Roman, Francisca Heredia, Ana Ma Sagarra,Angel Estella, F Brun, Elias Simon,Jose Manuel Torres,Elisa Lopera, F M Soriano, Fernando Santamarina, Matilde F Feixas, F Javier Hierro, Jose Ma Santos, A Perea, Francisco Tembury, Macarena Rizo, A Ramirez, Rafael Sindiones,Francisco Moya, A H Fernandez, Francisco Javier Molina Ruiz,Jose M Garrido, Enrique Almagro,Javier Povar,Elisa Aldea, M D Megias Rivas, Fernando Galve,Manuel Munoz,J Garcia, Pedro Cals, Ana Belen Bernardo Gutierrez,Luis Garciacastrillo,Maria Rodriguez,Fernando Richard, Beatriz Lopez, Luis Lapuerta, T Toranzo, Nicanor Zapico, Ana Melendre, Jose L Fernandez Aguilar, Ma Del Mar Sousa, Alberto Lopez, Luis M Montero, Raimundo Rodriguezbobada, Ramon Perales, Rosa Roldan,Carolina Fuenzalida,Olga Trejo,Alfons Aguirre, Teresa Soriano,Mireia Vila, Lluis Fornet, F Casarramona,M Sanchez, Font, Julio, Joan Espinach,Merce Almirall, Joaquin Danes,Alvaro Herrera, S Flores, Ali Jammoul, Jose Manuel Mateo Vicente, Ma Isabel Campos, Rafael Colomina, Joaquin Escamez, Begona Arcos,M Navarro,Javier Millan, Jose Javier Noceda, Salvador Rubini,Ricardo Rubini,Jose Carbajosa, M E Diaz, F J Navarro, Matilde Gonzalez, A Mateo, Cristina Gisbert,Ignacio Lopez,F Munoz,M T Garcia, Pablo Lamas,Luis Amador, R Calvo,Carmen Seijas, Ma C Selloso, F Aramburu, Ma A Lecinena, Alex Planas, I Ayala, J Alonso, B Buil Gutierrez, P Marco, B Rodriguez, Juan Parra,Juan Gonzalez, Luis E Diaz, Oscar Gabriel Davalos Alvarez, J A Andueza,G Jimenez, Manuel Ruizy, Esther Mora,Jesus Canora,Carlos Bibiano,Pascual Pinera, Enrique Retuerto, Jose Ma Melgares, J A Cruzado, Carmen Iglesias Escudero,Angel Gil Hernandez,Eduardo Garcia Jimenez, Jose Dario Sanchez Lopez

Annals of Emergency Medicine(2015)

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摘要
Study 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. Conclusion: 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.
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关键词
atrial fibrillation,stroke,emergency department
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