Unprotected discharge: absence of stroke prevention strategies in patients with atrial fibrillation admitted for bleedin
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Unprotected discharge: absence of stroke prevention strategies in patients with atrial fibrillation admitted for bleeding Sarah Gorgis 1 & Mohammed F. Dabbagh 1 & Kajali Mishra 2 & Guneet Ahluwalia 2 & Aeman Hana 2 & Georgi Fram 2 & Dilshan Dhillon 2 & Alejandro Lemor 1 & Arfaat Khan 1 & Daniel Miller 3 & Scott Kaatz 2 & William W. O’Neill 1 & Dee Dee Wang 1 Received: 22 August 2020 / Accepted: 19 October 2020 # Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Purpose Patients with atrial fibrillation or flutter (AF) on anticoagulation (AC) for stroke prevention are at an increased risk of bleeding. A common clinical dilemma is deciding when to safely restart AC following a bleed. Although studies have shown better outcomes with re-initiation of AC after hemostasis, there are clinical barriers to restarting AC. Left atrial appendage occlusion (LAAO) is a safe and efficacious alternative for patients who are unable to tolerate AC following major bleeding. We aimed to evaluate the rate of stroke prevention strategies instituted at time of discharge in patients with AF on AC who had been hospitalized for a bleeding event. Methods We retrospectively identified patients with AF on AC admitted for bleeding between January 2016 and August 2019. The type of AC, form of bleeding, and CHA2DS2VASc were collected. Stroke prevention strategies upon discharge and at 3 months were noted. Results One hundred seventy-four patients with AF on AC were hospitalized with a bleeding event, of which 10.9% died. Among patients who survived, AC was restarted in 45.2% of patients, 9.7% were referred for LAAO, and 45.1% were discharged without stroke prevention strategy. At 3 months, 32.6% of patients still had no documented stroke prophylaxis. Those referred for LAAO had, on average, higher CHA2DS2VASc (5 ± 1 vs 4 ± 1, p = 0.007). Conclusions A significant number of patients with AF hospitalized for bleeding were discharged with no plan for stroke prophylaxis. Despite its safety and efficacy, LAAO appears to be an underutilized alternative in AF patients with high bleeding risk. Keywords Atrial fibrillation . Stroke . Bleed . Left atrial appendage occlusion . Watchman
Abbreviations AF Atrial fibrillation or flutter AC Anticoagulation GIB Gastrointestinal bleed ICH Intracranial hemorrhage LAAO Left atrial appendage occlusion HFrEF Heart failure with reduced ejection fraction CKD Chronic kidney disease
* Dee Dee Wang [email protected] 1
Division of Cardiovascular Medicine, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202, USA
2
Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, USA
3
Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
ESRD DOAC NSAIDs PPIs
End-stage renal disease Direct oral anticoagulant Nonsteroidal anti-inflammatories Proton pump inhibitors
1 Introduction Patients with atrial fibrillation or flutter (AF) on anticoagulation (AC) for stroke prevention have an increased bleeding risk. A common clinical dilemma is deciding when, or if, to restart AC after
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