Ninety‐Day Stroke or Transient Ischemic Attack Recurrence in Patients Prescribed Anticoagulation in the Emergency Department With Atrial Fibrillation and a New Transient Ischemic Attack or Minor Stroke

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Atrial fibrillation and a new TIA or minor stroke (n=1286). Intervention: Emergency department-prescribed oral anticoagulation vs. No anticoagulant or already taking anticoagulant. Primary outcome: Composite of subsequent stroke, recurrent TIA, or all-cause mortality within 90 days (OR 1.37, 95% CI 0.74-2.52).

Graham Wilson; Mukul Sharma; Debra Eagles; Marie‐Joe Nemnom; Marco L.A. Sivilotti; Marcel Émond; Ian G. Stiell; Grant Stotts; Jacques Lee; Andrew Worster; Judy Morris; Ka Wai Cheung; Albert Jin; Wieslaw Oczkowski; Demetrios J. Sahlas; Heather Murray; Ariane Mackey; Steve Verreault; Marie‐Christine Camden; Samuel Yip; Philip Teal; David J. Gladstone; Mark I. Boulos; Nicolas Chagnon; Elizabeth Shouldice; Clare Atzema; Tarik Slaoui; Jeanne Teitlebaum; George A. Wells; Avik Nath; Jeffrey J. Perry

doi:10.1161/jaha.122.026681

Key result

ED-initiated oral anticoagulation fails to reduce 90-day stroke recurrence or death in minor stroke.

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Why the study?

For patients with atrial fibrillation presenting to the ED with TIA or minor stroke, the impact of initiating oral anticoagulation immediately versus deferring to outpatient follow-up was unknown.

Does emergency department-prescribed oral anticoagulation reduce 90-day recurrence of stroke, TIA, or death in patients with atrial fibrillation and a new TIA or minor stroke?

Key Points

To evaluate whether initiating oral anticoagulation in the emergency department reduces 90-day recurrent stroke, transient ischemic attack, or all-cause mortality in patients with atrial fibrillation presenting with a transient ischemic attack or minor stroke.
Conducted a planned secondary analysis of a prospective multicenter cohort of 11 507 adults across 13 Canadian emergency departments between 2006 and 2018.
Enrolled 1286 patients aged 18 years or older with atrial fibrillation and a final emergency department diagnosis of transient ischemic attack or minor stroke.
Evaluated the primary composite outcome of subsequent ischemic or hemorrhagic stroke, recurrent transient ischemic attack, or all-cause mortality within 90 days using multivariable logistic regression and blinded adjudication.
At 90 days across the 1286-patient cohort, 4.0% experienced a subsequent stroke, 6.5% experienced a transient ischemic attack, and 2.6% died.
Composite 90-day event rates were 16.9% with emergency department-prescribed anticoagulation, 10.2% for those already taking anticoagulation, and 12.8% for those without anticoagulation, with multivariable logistic regression showing no association between emergency prescription and outcome (composite OR, 1.37 [95% CI, 0.74-2.52]).
Major bleeding occurred in 5 patients (all intracerebral hemorrhages), none of whom were in the group with emergency department-initiated anticoagulation.

Study Design

Type

Cohort (n=1,286)

Multicenter

Yes

Structured PICO

Does emergency department-prescribed oral anticoagulation reduce 90-day recurrence of stroke, TIA, or death in patients with atrial fibrillation and a new TIA or minor stroke?

P

Population

1,286 adults (mean age 77.3, 47.6% female) with atrial fibrillation and a new TIA or minor stroke evaluated across 13 Canadian emergency departments, followed for 90 days.

E

Exposure

Initiation of oral anticoagulation (warfarin or direct oral anticoagulants) in the emergency department

C

Comparator

No anticoagulant prescribed in the ED, or already taking an anticoagulant prior to the index event

O

Outcome

Composite of subsequent stroke (ischemic or hemorrhagic), subsequent TIA, or all-cause mortality within 90 days of the index diagnosiscomposite

Main Result

Odds Ratio: 1.37 (95% CI 0.74–2.52)

Absolute Event Rate: 16.9% vs 12.8%

Initiating oral anticoagulation in the emergency department for patients with AF and a new TIA or minor stroke did not improve 90-day outcomes, suggesting the optimal timing for starting these medications remains complex and requires further study.

Limitations

Small number of patients prescribed anticoagulants in the ED
Uncertainty regarding patient compliance with prescribed anticoagulation post-discharge
Potential unmeasured confounders such as patient preference and physician comfort level

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Implication

ED initiation of anticoagulation was not associated with lower 90-day events; leaves open optimal timing after TIA or minor stroke in AF.

Abstract

Background For patients with atrial fibrillation seen in the emergency department (ED) following a transient ischemic attack (TIA) or minor stroke, the impact of initiating oral anticoagulation immediately rather than deferring the decision to outpatient follow-up is unknown. Methods and Results We conducted a planned secondary data analysis of a prospective cohort of 11 507 adults in 13 Canadian EDs between 2006 and 2018. Patients were eligible if they were aged 18 years or older, with a final diagnosis of TIA or minor stroke with previously documented or newly diagnosed atrial fibrillation. The primary outcome was subsequent stroke, recurrent TIA, or all-cause mortality within 90 days of the index TIA diagnosis. Secondary outcomes included stroke, recurrent TIA, or death and rates of major bleeding. Of 11 507 subjects with TIA/minor stroke, atrial fibrillation was identified in 11.2% (1286, mean age, 77.3 [SD 11.1] years, 52.4% male). Over half (699; 54.4%) were already taking anticoagulation, 89 (6.9%) were newly prescribed anticoagulation in the ED. By 90 days, 4.0% of the atrial fibrillation cohort had experienced a subsequent stroke, 6.5% subsequent TIA, and 2.6% died. Results of a multivariable logistic regression indicate no association between prescribed anticoagulation in the ED and these 90-day outcomes (composite odds ratio, 1.37 [95% CI, 0.74-2.52]). Major bleeding was found in 5 patients, none of whom were in the ED-initiated anticoagulation group. Conclusions Initiating oral anticoagulation in the ED following new TIA was not associated with lower recurrence rates of neurovascular events or all-cause mortality in patients with atrial fibrillation.

Discussion

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Cite This Study

Wilson et al. (2023) conducted a cohort in Atrial fibrillation and a new TIA or minor stroke (n=1,286). Emergency department-prescribed oral anticoagulation vs. No anticoagulant or already taking anticoagulant was evaluated on Composite of subsequent stroke, recurrent TIA, or all-cause mortality within 90 days (OR 1.37, 95% CI 0.74-2.52). ED-initiated oral anticoagulation for patients with atrial fibrillation and a new TIA/minor stroke did not reduce 90-day recurrence of stroke, TIA, or mortality (OR 1.37, 95% CI 0.74-2.52).

synapsesocial.com/papers/6a22343ae8ef4064f24ecf13 https://doi.org/10.1161/jaha.122.026681

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Ninety‐Day Stroke or Transient Ischemic Attack Recurrence in Patients Prescribed Anticoagulation in the Emergency Department With Atrial Fibrillation and a New Transient Ischemic Attack or Minor Stroke

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Ninety‐Day Stroke or Transient Ischemic Attack Recurrence in Patients Prescribed Anticoagulation in the Emergency Department With Atrial Fibrillation and a New Transient Ischemic Attack or Minor Stroke

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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