Oral Anticoagulation and Adverse Outcomes after Ischemic Stroke in Heart Failure Patients without Atrial Fibrillation.

BACKGROUND: The safety and effectiveness of oral anticoagulation (OAC) after an ischemic stroke in older patients with heart failure (HF) without atrial fibrillation remains uncertain. METHODS: Utilizing Get With The Guidelines Stroke national clinical registry data linked to Medicare claims from 2009-2014, we assessed the outcomes of eligible patients with a history of HF who were initiated on OAC during a hospitalization for an acute ischemic stroke. The cumulative incidences of adverse events were calculated using Kaplan-Meier curves and adjusted Cox proportional hazard ratios were compared between patients discharged on or off OAC. RESULTS: A total of 8,261 patients from 1,370 sites were discharged alive after an acute ischemic stroke and met eligibility criteria. Of those, 747 (9.0%) were initiated on OAC.  Patients on OAC were younger (77.2±8.0 vs. 80.5±8.9 years, p<0.01). After adjustment for clinical covariates, the likelihood of 1 year mortality was higher in those on OAC (aHR: 1.22, 95% CI 1.05-1.41, p<0.01), while no significant differences were noted for ICH (aHR: 1.34, 95% CI 0.69-2.59, p=0.38) and recurrent ischemic stroke (aHR: 0.78, 95% CI 0.54-1.15, p = 0.21).  The likelihood of all-cause bleeding (aHR: 1.59, 95% CI 1.29-1.96, p<0.01) and all-cause re-hospitalization (aHR: 1.14, 95% CI 1.02-1.27, p = 0.02) was higher for those on OAC. CONCLUSION: Initiation of OAC after an ischemic stroke in older patients with HF in the absence of atrial fibrillation is associated with death, bleeding and re-hospitalization without an associated reduction in recurrent ischemic stroke. If validated, these findings raise caution for prescribing OAC to such patients.

Comparison Between Anatomical and Functional Imaging Modalities for Evaluation of Chest Pain in the Emergency Department.

Evaluation of chest pain in the emergency department (ED) frequently employs a noninvasive strategy, including coronary computed tomography angiography (CCTA), stress echocardiography (SE), or myocardial perfusion imaging (MPI). We sought to report the real-world experience of utilizing CCTA compared with SE and MPI at an urban hospital ED. We conducted a retrospective cohort study of consecutively enrolled patients presenting with chest pain who had normal or nondiagnostic electrocardiogram (ECG), negative initial troponin-T, at least intermediate risk based on modified Diamond-Forrester criteria, and who underwent CCTA, SE, or MPI based on their individual test eligibility criteria. The primary outcome was ED discharge time. Secondary outcomes included test utilization and 30-days rehospitalization rates. The 2,143 patients who were included (mean age was 56 ± 12 years; 55% women) utilization rate (test performed/eligible) was lower for CCTA (n = 354/1,329) and MPI (n = 530/1,435) compared with SE (n = 1,259/1,650), p <0.001. Mean ED discharge times for both CCTA and SE were 12.5 ± 7.4 versus 16 ± 7.3 hours for MPI (p <0.0001). Patients with SE and CCTA were less likely to undergo coronary angiography (29%, 25%, vs 52% for MPI). There was a 1% cardiac-related 30-days rehospitalization rate in the CCTA group versus 1% in SE and 3% in the MPI group (p <0.01). In conclusion, CCTA and SE were associated with faster ED discharge and lower frequency of diagnostic coronary angiography. Notwithstanding its clinical utility, CCTA was underutilized at our large urban ED setting.