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Use of Oral Anticoagulant Therapy in Older Adults with Atrial Fibrillation After Acute Ischemic Stroke
Author(s) -
McGrath Emer R.,
Go Alan S.,
Chang Yuchiao,
Borowsky Leila H.,
Fang Margaret C.,
Reynolds Kristi,
Singer Daniel E.
Publication year - 2017
Publication title -
journal of the american geriatrics society
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.992
H-Index - 232
eISSN - 1532-5415
pISSN - 0002-8614
DOI - 10.1111/jgs.14688
Subject(s) - medicine , atrial fibrillation , stroke (engine) , dementia , odds ratio , confidence interval , logistic regression , retrospective cohort study , cohort , cohort study , psychological intervention , physical therapy , psychiatry , disease , mechanical engineering , engineering
Objectives To explore barriers to anticoagulation in older adults with atrial fibrillation ( AF ) at high risk of stroke and to identify opportunities for interventions that might increase use of oral anticoagulants ( OAC s). Design Retrospective cohort study. Setting Two large community‐based AF cohorts. Participants Individuals with ischemic stroke surviving hospitalization (N = 1,405, mean age 79). Measurements Using structured chart review, reasons for nonuse of OAC were identified, and 1‐year poststroke survival was assessed. Logistic regression was used to identify correlates of OAC nonuse. Results Median CHA 2 DS 2 ‐ VAS c score was 5, yet 44% of participants were not prescribed an OAC at discharge. The most‐frequent (nonmutually exclusive) physician reasons for not prescribing OAC included fall risk (26.7%), poor prognosis (19.3%), bleeding history (17.1%), participant or family refusal (14.9%), older age (11.0%), and dementia (9.4%). Older age (odds ratio ( OR ) = 8.96, 95% confidence interval ( CI ) = 5.01–16.04 for aged ≥85 vs <65) and disability ( OR = 12.58, 95% CI = 5.82–27.21 for severe vs no deficit) were the most‐important independent predictors of nonuse of OAC s. By 1 year, 42.5% of those not receiving an OAC at discharge had died, versus 19.1% of those receiving an OAC ( P < .001), far higher than recurrent stroke rates. Conclusion Despite very high stroke risk, more than 40% of participants were not discharged with an OAC . Dominant reasons included fall risk, poor prognosis, older age, and dementia. These individuals’ high 1‐year mortality rate confirmed their high level of comorbidity. To improve anticoagulation decisions and outcomes in this population, future research should focus on strategies to mitigate fall risk, improve assessment of risks and benefits of anticoagulation in individuals with AF , and determine whether newer anticoagulants are safer in complex elderly and frail individuals.