Phavalan Rajendram1,2,3, Krystal Fox4, Brindan Sivanandan1,2,3, Daniel Selchen1, Charles D Kassardjian1,3, Gustavo Saposnik5,6,7. 1. Division of Neurology, Department of Medicine, University of Toronto, Toronto, Canada. 2. Stroke Outcomes and Decision Neuroscience Research Unit, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada. 3. Neurology Quality and Innovation Lab, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 55 Queen St. E., Toronto, ON, M5C 1R6, Canada. 4. Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Canada. 5. Division of Neurology, Department of Medicine, University of Toronto, Toronto, Canada. gustavo.saposnik@unityhealth.to. 6. Stroke Outcomes and Decision Neuroscience Research Unit, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada. gustavo.saposnik@unityhealth.to. 7. Neurology Quality and Innovation Lab, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 55 Queen St. E., Toronto, ON, M5C 1R6, Canada. gustavo.saposnik@unityhealth.to.
Abstract
OBJECTIVES: Direct oral anticoagulants (DOACs) are indicated for preventing ischemic stroke in 95% of patients with atrial fibrillation (AF). However, DOACs are largely underutilized or inappropriately dosed. This study aimed to explore the rates of appropriate DOAC use between repatriated and non-repatriated patients with AF who presented with an acute ischemic stroke not deemed candidates for revascularization therapies. MATERIALS AND METHODS: Data were collected via electronic medical records and patients were contacted via telephone to obtain medication information and other missing clinical information. Multivariate logistic regression analyses were conducted to determine associations between appropriate use of a DOAC and repatriation status adjusting for age, sex, and comorbidities. RESULTS: A total of 49 patients were included in the study with a mean follow-up of 31.5 (± 11.9) months. Eleven patients (22.4%) died, and 4 (8.2%) patients were lost to follow-up. Overall, 9 (26.5%) patients (3 non-repatriated and 6 repatriated) were found to be on suboptimal or inappropriate anticoagulation. Repatriation was associated with over six fold (OR 6.53; 95% CI 1.20-35.7) likelihood of suboptimal or inappropriate anticoagulation. CONCLUSIONS: Awareness of this finding is critical to overcome therapeutic inertia in the use of DOACs for ischemic stroke patients with AF. With stroke care becoming increasingly nuanced, peripheral centers may lack the ability to guide anticoagulation in a timely and effective manner. Creation of tertiary short-term follow-up stroke clinics with cardiology follow-up may be an effective strategy to ensure standard of care. Research into systems contributors affecting the appropriate use of DOACs should be elucidated.
OBJECTIVES: Direct oral anticoagulants (DOACs) are indicated for preventing ischemic stroke in 95% of patients with atrial fibrillation (AF). However, DOACs are largely underutilized or inappropriately dosed. This study aimed to explore the rates of appropriate DOAC use between repatriated and non-repatriated patients with AF who presented with an acute ischemic stroke not deemed candidates for revascularization therapies. MATERIALS AND METHODS: Data were collected via electronic medical records and patients were contacted via telephone to obtain medication information and other missing clinical information. Multivariate logistic regression analyses were conducted to determine associations between appropriate use of a DOAC and repatriation status adjusting for age, sex, and comorbidities. RESULTS: A total of 49 patients were included in the study with a mean follow-up of 31.5 (± 11.9) months. Eleven patients (22.4%) died, and 4 (8.2%) patients were lost to follow-up. Overall, 9 (26.5%) patients (3 non-repatriated and 6 repatriated) were found to be on suboptimal or inappropriate anticoagulation. Repatriation was associated with over six fold (OR 6.53; 95% CI 1.20-35.7) likelihood of suboptimal or inappropriate anticoagulation. CONCLUSIONS: Awareness of this finding is critical to overcome therapeutic inertia in the use of DOACs for ischemic stroke patients with AF. With stroke care becoming increasingly nuanced, peripheral centers may lack the ability to guide anticoagulation in a timely and effective manner. Creation of tertiary short-term follow-up stroke clinics with cardiology follow-up may be an effective strategy to ensure standard of care. Research into systems contributors affecting the appropriate use of DOACs should be elucidated.