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Factors Associated with Anticoagulation Delay Following New-Onset Atrial Fibrillation

      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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      References

        • Corley S.D.
        • Epstein A.E.
        • DiMarco J.P.
        • Domanski M.J.
        • Geller N.
        • Greene H.L.
        • Josephson R.A.
        • Kellen J.C.
        • Klein R.C.
        • Krahn A.D.
        • Mickel M.
        • Mitchell L.B.
        • Nelson J.D.
        • Rosenberg Y.
        • Schron E.
        • Shemanski L.
        • Waldo A.L.
        • Wyse D.G.
        • Investigators A.
        Relationships between sinus rhythm, treatment, and survival in the atrial fibrillation follow-up investigation of rhythm management (AFFIRM) study.
        Circulation. 2004; 109: 1509-1513
        • Stewart S.
        • Hart C.L.
        • Hole D.J.
        • McMurray J.J.V.
        A population-based study of the long-term risks associated with atrial fibrillation: 20-year follow-up of the Renfrew/Paisley Study.
        Am J Med. 2002; 113: 359-364
        • Wolf P.A.
        • Abbott R.D.
        • Kannel W.B.
        Atrial-fibrillation—a major contributor to stroke in the elderly—the Framingham Study.
        Arch Intern Med. 1987; 147: 1561-1564
        • Adam S.S.
        • McDuffie J.R.
        • Ortel T.L.
        • Williams J.W.
        Comparative effectiveness of warfarin and new oral anticoagulants for the management of atrial fibrillation and venous thromboembolism: a systematic review.
        Ann Intern Med. 2012; 157: 796-807
        • January C.T.
        • Wann L.S.
        • Alpert J.S.
        • Calkins H.
        • Cigarroa J.E.
        • Cleveland J.C.
        • Conti J.B.
        • Ellinor P.T.
        • Ezekowitz M.D.
        • Field M.E.
        • Murray K.T.
        • Sacco R.L.
        • Stevenson W.G.
        • Tchou P.J.
        • Tracy C.M.
        • Yancy C.W.
        • Anderson J.L.
        • Halperin J.L.
        • Albert N.M.
        • Bozkurt B.
        • Brindis R.G.
        • Creager M.A.
        • Curtis L.H.
        • DeMets D.
        • Guyton R.A.
        • Hochman J.S.
        • Kovacs R.J.
        • Ohman E.M.
        • Pressler S.J.
        • Sellke F.W.
        • Shen W.K.
        2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation.
        J Am Coll Cardiol. 2014; 64: E1-E76
        • Olesen J.B.
        • Torp-Pedersen C.
        • Hansen M.L.
        • Lip G.Y.H.
        The value of the CHA(2)DS(2)-VASc score for refining stroke risk stratification in patients with atrial fibrillation with a CHADS(2) score 0–1: a nationwide cohort study.
        Thromb Haemost. 2012; 107: 1172-1179
        • Waldo A.L.
        • Becker R.C.
        • Tapson V.F.
        • Colgan K.J.
        • Comm N.S.
        Hospitalized patients with atrial fibrillation and a high risk of stroke are not being provided with adequate anticoagulation.
        J Am Coll Cardiol. 2005; 46: 1729-1736
        • Wilke T.
        • Groth A.
        • Mueller S.
        • Pfannkuche M.
        • Verheyen F.
        • Linder R.
        • Maywald U.
        • Kohlmann T.
        • Feng Y.S.
        • Breithardt G.
        • Bauersachs R.
        Oral anticoagulation use by patients with atrial fibrillation in Germany adherence to guidelines, causes of anticoagulation under-use and its clinical outcomes, based on claims-data of 183,448 patients.
        Thromb Haemost. 2012; 107: 1053-1065
        • Khurshid S.
        • Keaney J.
        • Ellinor P.T.
        • Lubitz S.A.A.
        Simple and portable algorithm for identifying atrial fibrillation in the electronic medical record.
        Am J Cardiol. 2016; 117: 221-225
        • Fuster V.
        • Ryden L.E.
        • Cannom D.S.
        • Crijns H.J.
        • Curtis A.B.
        • Ellenbogen K.A.
        • Halperin J.L.
        • Le Heuzey J.Y.
        • Kay G.N.
        • Lowe J.E.
        • Olsson S.B.
        • Prystowsky E.N.
        • Tamargo J.L.
        • Wann S.
        ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 guidelines for the management of patients with atrial fibrillation) developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.
        Circulation. 2006; 114: E257-E354
        • Friberg L.
        • Rosenqvist M.
        • Lip G.Y.H.
        Evaluation of risk stratification schemes for ischaemic stroke and bleeding in 182 678 patients with atrial fibrillation: the Swedish Atrial Fibrillation Cohort Study.
        Eur Heart J. 2012; 33: 1500-1510
        • R Core Team
        R: A Language and Environment for Statistical Computing.
        R Foundation for Statistical Computing, Vienna, Austria2015 (Available at:)
        https://www.R-project.org/
        Date accessed: March 18, 2016
        • Lip G.Y.H.
        • Nieuwlaat R.
        • Pisters R.
        • Lane D.A.
        • Crijns H.
        Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach the Euro Heart Survey on atrial fibrillation.
        Chest. 2010; 137: 263-272
        • Hsu J.C.
        • Maddox T.M.
        • Kennedy K.
        • Katz D.F.
        • Marzec L.N.
        • Lubitz S.A.
        • Gehi A.K.
        • Turakhia M.P.
        • Marcus G.M.
        Aspirin instead of oral anticoagulant prescription in atrial fibrillation patients at risk for stroke.
        J Am Coll Cardiol. 2016; 67: 2913-2923
        • Man-Son-Hing M.
        • Nichol G.
        • Lau A.
        • Laupacis A.
        Choosing antithrombotic therapy for elderly patients with atrial fibrillation who are at risk for falls.
        Arch Intern Med. 1999; 159: 677-685
        • Lee A.Y.Y.
        • Levine M.N.
        • Baker R.I.
        • Bowden C.
        • Kakkar A.K.
        • Prins M.
        • Rickles F.R.
        • Julian J.A.
        • Haley S.
        • Kovacs M.J.
        • Gent M.
        • CLOT
        Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer.
        New Engl J Med. 2003; 349: 146-153
        • Kaatz S.
        • Douketis J.D.
        • Zhou H.
        • Gage B.F.
        • White R.H.
        Risk of stroke after surgery in patients with and without chronic atrial fibrillation.
        Thromb Haemost. 2010; 8: 884-890