Identifying secondary stroke prevention treatment gaps in older patients with nonvalvular atrial fibrillation

<h2>Abstract</h2><h3>Background</h3> Current guidelines for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF) recommend oral anticoagulation (OAC). The risk of stroke is particularly increased in older patients and those with a history of stroke. Previous studies suggested up to 67% of eligible patients with NVAF are not prescribed OAC. <h3>Objective</h3> This study aimed to identify gaps in OAC prescribing patterns for older patients with NVAF and previous stroke to allow for optimization of OAC prescribing. <h3>Methods</h3> This single-center retrospective cohort study was conducted from a multispecialty group practice affiliated with a 178-bed community hospital. The sites are located in the Seacoast region of New Hampshire and Southern Maine. Participants included older adults aged 65-89 years with NVAF and previous stroke who were not prescribed OAC with at least1 ambulatory encounter between July 1, 2022, and June 30, 2023. Pharmacists identified patients using existing databases of ICD-10 codes, medication lists, and ambulatory clinic encounters. The primary outcome was to identify the cohort of patients not prescribed OAC. <h3>Results</h3> Among 391 eligible patients, 48 (12.3%) were not prescribed OAC therapy. Of the 48 elderly patients with NVAF and stroke history without OAC, 21 (43.5%) did not have a guideline-directed indication for OAC omission. Rationale for OAC omission included cost (6.3%), patient refusal (29.2%), bleeding from isolated trauma or procedural complication (4.2%), falls (18.8%), previous intracranial or intraspinal hemorrhage (8.3%), severe bleeding owing to nonreversible cause (4.2%), and transient NVAF (25%). Patients with Medicare were more likely to lack OAC (60%). <h3>Conclusion</h3> Not all patients who were indicated for OAC were prescribed OAC highlighting opportunity to improve prescribing practices. Uncovering real-world rationales for OAC omission equips pharmacists with valuable insights to address patient concerns effectively and highlights the critical role of pharmacist-led patient education in improving prescribing practices.