Emergency Medicine Physician Attitudes toward Anticoagulant Initiation for Patients with Atrial Fibrillation

Background and Aim: Guidelines for the primary prevention of stroke recognize the emergency department as a location for physicians to identify atrial fibrillation and to initiate oral anticoagulants. Numerous studies have shown low anticoagulant prescription rates—approximately 18%—in OAC-naïve patients with atrial fibrillation discharged from the emergency department. We sought to obtain the opinions of Emergency Medicine physicians regarding anticoagulant decision-making for patients with atrial fibrillation seen in the emergency department. Methods: 14-item paper surveys were distributed to emergency department physicians within a single hospital system. The survey consisted of single-, multi- answer and open-ended questions regarding knowledge and usage frequency of the CHA₂DS₂-VASc score, knowledge of anticoagulant options and reasons for why an anticoagulant was not initiated. Results: 55 emergency department physicians completed the survey (overall response rate 59%). 89% (49/55) agreed the emergency department is an important location to initiate anticoagulation depending on comorbidities. A lower proportion reported ever starting a patient in the emergency department on a new anticoagulant prescription upon discharge (55% (30/55) p <.0001). The belief that a new anticoagulant prescription is the responsibility of the PCP/ Cardiologist/ Neurologist (52%; 15/29), not wanting to be held responsible in the event of a life-threatening bleeding event (41%; 12/29), and concerns about inadequate follow-up and/or lack of insurance (24%; 7/29) were the most commonly cited reasons for not starting an appropriate patient with atrial fibrillation on an anticoagulant. Conclusion: Emergency Medicine physicians support initiating oral anticoagulants in the ED for patients with atrial fibrillation; however, discrepancies exist between their intentions and actual practice.