INTRODUCTION: Many patients with atrial fibrillation or atrial flutter (AF/FL) 
who are high risk for ischemic stroke are not receiving evidence-based 
thromboprophylaxis. We examined anticoagulant prescribing within 30 days of 
receiving dysrhythmia care for non-valvular AF/FL in the emergency department 
(ED).
METHODS: This prospective study included non-anticoagulated adults at high risk 
for ischemic stroke (ATRIA score ≥7) who received emergency AF/FL care and were 
discharged home from seven community EDs between May 2011 and August 2012. We 
characterized oral anticoagulant prescribing patterns and identified predictors 
of receiving anticoagulants within 30 days of the index ED visit. We also 
describe documented reasons for withholding anticoagulation.
RESULTS: Of 312 eligible patients, 128 (41.0%) were prescribed anticoagulation 
at ED discharge or within 30 days. Independent predictors of anticoagulation 
included age (adjusted odds ratio [aOR] 0.89 per year, 95% confidence interval 
[CI] 0.82-0.96); ED cardiology consultation (aOR 1.89, 95% CI [1.10-3.23]); and 
failure of sinus restoration by time of ED discharge (aOR 2.65, 95% CI 
[1.35-5.21]). Reasons for withholding anticoagulation at ED discharge were 
documented in 139 of 227 cases (61.2%), the most common of which were deferring 
the shared decision-making process to the patient's outpatient provider, 
perceived bleeding risk, patient refusal, and restoration of sinus rhythm.
CONCLUSION: Approximately 40% of non-anticoagulated AF/FL patients at high risk 
for stroke who presented for emergency dysrhythmia care were prescribed 
anticoagulation within 30 days. Physicians were less likely to anticoagulate 
older patients and those with ED sinus restoration. Opportunities exist to 
improve rates of thromboprophylaxis in this high-risk population.