Oral anticoagulation (OAC) is effective yet reportedly underutilized for stroke prevention
in atrial fibrillation (AF). Factors associated with delayed OAC after incident AF
are unknown. Using a large electronic medical record, we identified incident episodes
of AF diagnosed in 2006 to 2014 using a validated algorithm. Among patients with a
Congestive heart failure, Hypertension, Age, Diabetes, and Stroke (CHADS2) score ≥1 started on OAC within 1 year, we examined baseline characteristics at AF
diagnosis and their association with time to OAC using multivariable Cox proportional
hazards modeling. Of 4,388 patients with incident AF and CHADS2 score ≥1 who were started on OAC within 1 year, the mean age was 72.6, and 41% were
women. Median time to OAC was 5 days (interquartile range 1 to 43), and most patients
received warfarin (86.3%). Among patients without prevalent stroke, 98 strokes (2.2%
of the sample) occurred between AF diagnosis and OAC initiation. In multivariable
analyses, several factors were associated with delayed OAC including female gender
(hazard ratio [HR] 1.08, 95% confidence interval [CI] 1.01 to 1.15), absence of hypertension
(HR 1.15, 95% CI 1.03 to 1.27), previous fall (HR 1.53, 95% CI 1.08 to 2.17), and
chronic kidney disease (HR 1.12, 95% CI 1.04 to 1.21). Among women, OAC prescription
at 1, 3, and 6 months was 70.0%, 81.7%, and 89.5%, respectively, whereas for men,
OAC prescription was 73.4%, 84.0%, and 91.5%, respectively. Most patients with new
AF and elevated stroke risk started on OAC receive it within 1 week, although the
promptness of initiation varies. The stroke rate is substantial in the period between
AF diagnosis and OAC initiation. Interventions targeting identified risk factors for
delayed OAC may result in improved outcomes.
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Article Info
Publication History
Published online: July 24, 2017
Accepted:
July 5,
2017
Received:
May 2,
2017
Footnotes
See page 1320 for disclosure information.
Dr. Lubitz is supported by NIH grant K23HL114724 and by Doris Duke Charitable Foundation Awards 2014105 (Lubitz) and 2016077 (Lubitz / Hulme) . This work was also supported by grants from the National Institutes of Health to Dr. Ellinor ( 1RO1HL092577 , R01HL128914 , K24HL105780 ). Dr. Ellinor is also supported by an Established Investigator Award from the American Heart Association ( 13EIA14220013 ) and by the Fondation Leducq ( 14CVD01 ).
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