• Emer R McGrath, Alan S Go, Yuchiao Chang, Leila H Borowsky, Margaret C Fang, Kristi Reynolds, and Daniel E Singer.
• Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts.
• J Am Geriatr Soc. 2017 Feb 1; 65 (2): 241-248.

ObjectivesTo explore barriers to anticoagulation in older adults with atrial fibrillation (AF) at high risk of stroke and to identify opportunities for interventions that might increase use of oral anticoagulants (OACs).DesignRetrospective cohort study.SettingTwo large community-based AF cohorts.ParticipantsIndividuals with ischemic stroke surviving hospitalization (N = 1,405, mean age 79).MeasurementsUsing structured chart review, reasons for nonuse of OAC were identified, and 1-year poststroke survival was assessed. Logistic regression was used to identify correlates of OAC nonuse.ResultsMedian CHA2 DS2 -VASc score was 5, yet 44% of participants were not prescribed an OAC at discharge. The most-frequent (nonmutually exclusive) physician reasons for not prescribing OAC included fall risk (26.7%), poor prognosis (19.3%), bleeding history (17.1%), participant or family refusal (14.9%), older age (11.0%), and dementia (9.4%). Older age (odds ratio (OR) = 8.96, 95% confidence interval (CI) = 5.01-16.04 for aged ≥85 vs <65) and disability (OR = 12.58, 95% CI = 5.82-27.21 for severe vs no deficit) were the most-important independent predictors of nonuse of OACs. By 1 year, 42.5% of those not receiving an OAC at discharge had died, versus 19.1% of those receiving an OAC (P < .001), far higher than recurrent stroke rates.ConclusionDespite very high stroke risk, more than 40% of participants were not discharged with an OAC. Dominant reasons included fall risk, poor prognosis, older age, and dementia. These individuals' high 1-year mortality rate confirmed their high level of comorbidity. To improve anticoagulation decisions and outcomes in this population, future research should focus on strategies to mitigate fall risk, improve assessment of risks and benefits of anticoagulation in individuals with AF, and determine whether newer anticoagulants are safer in complex elderly and frail individuals.© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.

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