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Identifying gaps in the management of atrial fibrillation with anticoagulation for stroke prevention (GIANTS): a quality improvement initiative

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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.

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Acknowledgements

The authors are grateful to all participants and their family members. We also appreciate the support from the Stroke program and Leadership at the Unity Health Toronto- St. Michael’s Hospital site for facilitating the implementation of the study.

Funding

Division of Neurology, Institut de Recherches Servier.

Author information

Authors and Affiliations

  1. Division of Neurology, Department of Medicine, University of Toronto, Toronto, Canada

    Phavalan Rajendram, Brindan Sivanandan, Daniel Selchen, Charles D. Kassardjian & Gustavo Saposnik

  2. Stroke Outcomes and Decision Neuroscience Research Unit, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada

    Phavalan Rajendram, Brindan Sivanandan & Gustavo Saposnik

  3. Neurology Quality and Innovation Lab, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 55 Queen St. E., Toronto, ON, M5C 1R6, Canada

    Phavalan Rajendram, Brindan Sivanandan, Charles D. Kassardjian & Gustavo Saposnik

  4. Division of Neurosurgery, Department of Surgery, St. Michael’s Hospital, University of Toronto, Toronto, Canada

    Krystal Fox

Authors
  1. Phavalan Rajendram
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  2. Krystal Fox
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  3. Brindan Sivanandan
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  4. Daniel Selchen
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  5. Charles D. Kassardjian
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  6. Gustavo Saposnik
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Corresponding author

Correspondence to Gustavo Saposnik.

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Conflicts of interest

This study was supported by the Division of Neurology and the Stroke program at the Unity Health Toronto. The Division of Neurology received an unrestricted grant from Servier Canada. The authors received no compensation for conducting the study.

Ethical approval

The present study was approved by the appropriate ethics committee and have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.

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Rajendram, P., Fox, K., Sivanandan, B. et al. Identifying gaps in the management of atrial fibrillation with anticoagulation for stroke prevention (GIANTS): a quality improvement initiative. J Neurol 269, 5047–5051 (2022). https://doi.org/10.1007/s00415-022-11159-y

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  • DOI: https://doi.org/10.1007/s00415-022-11159-y

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