Oral anticoagulation therapy upon discharge in hospitalized patients with nonvalvular atrial fibrillation: a retrospective cohort study

Objectives: Availability of direct oral anticoagulants and CHA₂DS₂VASc/HAS-BLED scoring tools underscore the importance of appropriate and safe use of oral anticoagulation therapy (OACT). The purpose of this study was to evaluate stroke prevention pharmacotherapy in adult patients with nonvalvular atrial fibrillation (NVAF) discharged from a large, community-based hospital.

Methods: A retrospective cohort study was conducted using a de-identified data collection sheet for data extraction (demographics, admitting diagnosis, OACT prior to admission and at discharge, concomitant medications that could increase bleed risk and/or acid-suppressive therapies). CHA₂DS2VASc and HAS-BLED scores were calculated. Descriptive statistics were generated to describe all parameters. Frequency counts and percentages summarized categorical variables while mean ± standard deviation were determined for continuous variables.

Results: Data from 180 patients were evaluated and of these 177 (98.3%) received OACT regardless of stroke risk upon discharge, as determined by CHA₂DS₂VASc scoring tool. The mean CHA₂DS₂VASc and HAS-BLED scores were 3.61 ± 1.7 and 2.13 ± 1.26, respectively. At discharge, eight patients at low-stroke risk received OACT for unclear reasons, one intermediate-stroke risk patient received aspirin only, and two patients at high-stroke risk did not receive OACT due to concerns about bleeds. In 66 patients at high-bleed risk, only half received concomitant acid-suppressive therapy.

Conclusions: Decision to add OACT is often guideline-driven, however, individualized circumstances in which clinicians and patients find themselves are also important considerations. Determination of ischemic stroke risk should be performed with CHA₂DS₂VASc scoring tool to exclude patients who may not benefit from OACT. HAS-BLED scoring tool should be used to identify any modifiable bleeding risk factors present with subsequent initiation of management strategies. Availability of complete medical histories and meticulous documentation are necessary for multiple clinicians to continuously determine optimal pharmacotherapy during follow-up visits.