Evaluation of Appropriate Anticoagulation Use in

Patients with Atrial Fibrillation for Primary and

Secondary Prevention of Stroke Within a VAMC
Jordan Trively, PharmD
PGY-1 Pharmacy Resident
Veteran Health Indiana, Indianapolis, IN
The speaker has no actual or potential conflicts of interest to
disclose in relation to this presentation
Background
Background
• Atrial fibrillation (AF) is an independent risk factor for
strokes
– Present in 1/3 of all ischemic stroke patients
– Accounts for at least 1/2 of all cardioembolic strokes

• Oral anticoagulation is used in atrial fibrillation for

stroke prevention
– Evidence suggests it may be under-prescribed or under-
dosed

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Freedman B, Potpara TS, Lip GYH. Lancet. 2016;388:806-17.

Background

• 83.5% of patients with a CHADS2-VASc score of ≥ 2

were not receiving adequate therapeutic
anticoagulation prior to a stroke
• Atrial fibrillation patients taking warfarin only
achieved therapeutic range 46.3% of the time

VETERANS HEALTH ADMINISTRATION Xian Y, O’Brien EC, Liang L. J AmColl Cardiol. 2017;317:1057-67
Dlott JS, George RA, Huang X Circulation. 2014;129:1407-14
Background

• Strokes in atrial fibrillation patients are associated

with greater mortality compared to strokes in non-
atrial fibrillation patients (14.1% to 6.2%)
• After 55 years of age, each successive decade
doubles the stroke risk in both men and women

Kongbunkiat K, Kasemsap N, Travanichakul S. International J Neuroscience.

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2015;125:924-928
Michael K M, Shaughnessy M. Journal of Cardiovascular Nursing. 2006;21:S21-26
Current Guidelines
• Oral anticoagulants are recommended for patients with
AF with a CHA2DS2-VASc score of ≥ 2 in men or ≥ 3 in
women
• Direct Oral Anticoagulants (DOACs) are recommended
over warfarin in patients that are eligible for DOACs
– Not eligible: moderate-to-severe mitral stenosis or a
mechanical heart valve
• DOACs have been shown to be superior or at least
noninferior in trials to warfarin (VKA)

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January GT, Samuel W, Joseph S. Circulation. 2019; 140:e125-51

CHA2DS2-VASc Score

Clinical prediction tool for stroke risk

estimation in AF patients

Stratifies nonvalvular AF patients into

stroke risk categories

Higher-risk categories may benefit

from anticoagulation

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CHA2DS2-VASc Score
Risk Factor
C CHF
H Hypertension
A Age ≥ 75 years
D Diabetes Mellitus
S Prior Stroke, TIA
V Vascular disease
A Age 64-75 years
Sc Sex category
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Points Score Stroke Risk (%)
1 0 0
1 1 1.3
1 2 2.2
1 3 3.2
2 4 4.0
1 5 6.7
1 6 9.8
1 7 9.6
8 6.7
9 15.2
Lip GY, Nieuwlaat R, Pisters R. Chest. 2010;137:263-72
Anticoagulant Treatment Options

DOACs VKA
• Apixaban • Warfarin
• Rivaroxaba with goal
n INR 2-3
• Edoxaban
• Dabigatran

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Background
• Veteran Health Indiana (VHI) has had an official
stroke committee since March of 2014 and became a
Joint Commission Primary Stroke Center in 2018
• Oral anticoagulation prescribing has not been
evaluated at VHI for primary and secondary
prevention of stroke for atrial fibrillation patients
since the stroke center’s inception

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Veteran Health Indiana
Indianapolis, IN

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Knowledge Check
Question #1
Which of the following risk factors is NOT a
part of the CHA2DS2-VASc score?
A. Age > 65 years
B. Sex category
C. Obesity
D. Diabetes Mellitus

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Question #1
Which of the following risk factors is NOT a
part of the CHA2DS2-VASc score?
A. Age > 65 years
B. Sex category
C. Obesity
D. Diabetes Mellitus

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Question #2
A 80 YOM patient has atrial fibrillation, a SCr of
1.01, and weighs 56 kg. What dose of apixaban
would be recommended for this patient?
A. 2.5 mg PO BID
B. 5 mg PO BID
C. 2.5 mg PO daily
D. 5 mg PO daily

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Question #2
A 80 YOM patient has atrial fibrillation, a SCr of
1.01, and weighs 56 kg. What dose of apixaban
would be recommended for this patient?
A. 2.5 mg PO BID
B. 5 mg PO BID
C. 2.5 mg PO daily
D. 5 mg PO daily

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Purpose and Methods
Primary Objective

Evaluate appropriateness of
anticoagulation in patients who have
presented with acute ischemic stroke

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Secondary Objectives

• Characterize current anticoagulant prescribing

• Identify potential areas for improvement for
stroke prevention in patients with atrial
fibrillation/flutter at Veteran Health Indiana

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Study Design
• Qualitative, retrospective, electronic chart
review
• Patients with atrial fibrillation or atrial flutter
who were admitted for stroke
• Data from June 1, 2018 to July 31, 2020

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 Study Endpoints
• Appropriateness of anticoagulation therapies
Primary for patients with atrial fibrillation who have
endpoint had a stroke based on current treatment
guidelines

• Therapies utilized categorized by CHA2DS2-

VASc and HAS-BLED score at time of AF
Secondary diagnosis and at time of discharge
endpoints • Dosing of anticoagulant
• Medication adherence
• Warfarin time in therapeutic range

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Inclusion Criteria

• Age ≥ 18 years of age

• Diagnosis code of atrial fibrillation or atrial
flutter AND first time use of diagnosis code for
ischemic stroke between June 1, 2018 to July
31, 2020

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Exclusion Criteria
• Pregnant patients
• Patients in hospice care
• Diagnosis of atrial fibrillation unknown or ≤ 30
days prior to stroke
• Diagnosis of cryptogenic stroke, strokes from
septic emboli, or any other stroke outside of
inclusion criteria

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Inclusion Breakdown
146 patients
39 had stroke outside
of study time frame
33 no evidence
of stroke
31 stroke at
8 non outside hospital
cardioembolic

30
5 “other”
patients
included
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Results
Baseline Demographics (N = 30)
Age (years) 72 (55-90)
Gender 30 male
0 female
BMI 35.8 (15.8-63.1)
Pertinent Past Medical History
Hyperlipidemia 73%
Cancer 27%
Tobacco use 40%

CHA2DS2-VASc score 3 (0-5)

HAS-BLED score 2 (0-4)
Creatinine clearance 83.3 (43-156)
NIHSS
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HEALTH ADMINISTRATION 5 (0-22)
Baseline Demographics
Anticoagulant Breakdown (n=20)
Apixaban (n) 5
Rivaroxaban (n) 3
Dabigatran (n) 1
Warfarin (n) 3
Aspirin (n) 2
DOAC + Antiplatelet (n) 6
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 Anticoagulation & CHA2DS2-VASc
at Time of Stroke
P e rce n ta g e o f P a ti e n ts

50% CHA2DS2-VASc: 0-2 (n=5)

43% CHA2DS2-VASc: 3 (n=11)
40% 40%
40% 36% CHA2DS2-VASc: 4-5 (n=14) 36%

30% 27% 29%

20% 21%
20%

10% 7%
0% 0%
0%

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Anticoagulation & CHA2DS2-VASc
at Time of AF Diagnosis
P e rc e n t a g e o f P a ti e n t s

90% 86%
80% CHA2DS2-VASc: 0-2 (n=12)
71%
70% 67% CHA2DS2-VASc: 3 (n=7)
60% CHA2DS2-VASc: 4-5 (n=7)
50%
40%
30% 29%
25%
20% 14%
10% 8%
0% 0% 0% 0% 0%
0%

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Anticoagulation & HAS-BLED
at Time of Stroke
P e rc e n ta g e o f P a ti e n ts

50%
50%
42%
HAS-BLED 0-2 (N=18) 39%
40%
HAS-BLED 3-4 (N=12)
30%
25% 25%
20%

10% 8%
6% 6%

0%

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Anticoagulation & HAS-BLED at
Time of AF Diagnosis
P e rc e n ta g e o f P a ti e n ts

90%
HAS-BLED 0-2 (N=22)
80% 77%
HAS-BLED 3-4 (N=4)
70%
60%
50% 50%
50%
40%
30%
20% 18%
10% 5%
0% 0% 0%
0%

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Therapies Utilized at Time of
Discharge

10%
Anticoagulation only
Antiplatelet only
30% Anticoagulant +
60% Antiplatelet
No anticoagulant

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 Appropriateness of
Anticoagulation DOAC

6%
Underdose

94%
Appropriately dosed

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 Appropriateness of Anticoagulation
Warfarin
Only 3
patients on
warfarin at
time of
stroke

Only 2
patients
had TTR
available

TTR:
48% and
92%
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Refill Adherence
• Defined by number of monthly refills divided by 6
months prior to stroke
– 90-day supply accounted for 3 months of refills

• Refill adherence: 73%

– 4.4 monthly refills per 6 months
– Variance: 0% - 100%
– Unable to evaluate refill adherence for aspirin

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No Anticoagulation

Reason for no anticoagulation on admission (n = 10)

Patient refusal 3
Bleeding 1
Unclear 6

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Discussion
Conclusion

Anticoagulation was most often not taken with

CHA2DS2-VASc of 3 or less; however, at least 20% of
each baseline stroke category were not on
anticoagulation at time of stroke (range: 20% - 50%)

Most patients prescribed DOACs were appropriately

dosed, however patients only refilled their
anticoagulation medications 4 months out of the 6
months prior to stroke

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Conclusion

Almost 20% of patients on anticoagulation at time

of AF were NOT on anticoagulation and/or
antiplatelet at time of stroke

Most patients at increased risk for bleeding (HAS-

BLED score of 3-4) were on both anticoagulant +
antiplatelet. Most patients with lower risk (HAS-
BLED of 0-2) were not on any anticoagulation

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Conclusion

More questions
than answers

Switching to more
Confusion on
Refills? convenient DOAC
restarting
from warfarin

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Limitations
Patient population
• Small sample size may not reflect overall prescribing
within the VA
• May not be able to generalize to other populations

Limited to documentation within the VA

• Could not assess patients on anticoagulation prescribed outside
of the VA
• Lack of documentation may not provide enough insight into
prescriber or patient reasoning

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Future Directions
Evaluate gaps in care and prescribing that can
be addressed and improved

Create educational training for providers to

maximize benefit and reduce harm

Continuous reassessment of appropriate and

safe anticoagulation prescribing and
monitoring
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Acknowledgements

Kristin Gaby, PharmD, BCACP

Clinical Pharmacy Specialist, Anticoagulation Clinic

Tiffany Boelke, PharmD, BCACP

Interim Assistant Chief, Pharmacy Service

Andrea Kingsolver, PharmD, BCPS

Clinical Staff Pharmacist, Inpatient

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Evaluation of Appropriate Anticoagulation Use in
Patients with Atrial Fibrillation for Primary and
Secondary Prevention of Stroke Within a VAMC
Jordan Trively, PharmD
Jordan.trively1@va.gov

The speaker has no actual or potential conflicts of interest to

disclose in relation to this presentation