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Addy K, Joyce LR, Al-Busaidi IS, Pickering JW, Troughton R, Than M. Implementation of an integrated emergency department acute atrial fibrillation pathway safely reduces cardioversions and hospitalisations: A comparative pre-post study. Emerg Med Australas 2023; 35:828-833. [PMID: 37169715 DOI: 10.1111/1742-6723.14240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/03/2023] [Accepted: 04/27/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVE Atrial fibrillation/flutter (AF/AFL) accounts for high rates of ED presentations and hospital admissions. There is increasing evidence to suggest that delaying cardioversion for acute uncomplicated AF is safe, and that many patients will spontaneously revert to sinus rhythm (SR). We conducted a before-and-after evaluation of AF/AFL management after a change in ED pathway using a conservative 'rate-and-wait' approach, incorporating next working day outpatient clinic follow-up and delayed cardioversion if required. METHODS We performed a before-and-after retrospective cohort study examining outcomes for patients who presented to the ED in Christchurch, New Zealand, with acute uncomplicated AF/AFL in the 1-year period before and after the implementation of a new conservative management pathway. RESULTS A total of 360 patients were included in the study (182 'Pre-pathway' vs 178 'Post-Pathway'). Compared to the pre-pathway cohort, those managed under the new pathway had an 81.2% reduction in ED cardioversions (n = 32 vs n = 6), and 50.7% reduction in all cardioversions (n = 65 vs n = 32). There was a 31.6% reduction in admissions from ED (n = 54 vs n = 79). ED length of stay (3.9 h vs 3.8 h, net difference -0.1 h, 95% confidence interval [CI] -0.6 to 0.3), 1-year ED AF representation (32.4% vs 26.4%, net difference -6.0% [95% CI -16.0% to 3.9%]), 1-year ED ischaemic stroke presentation (2.2% in both groups) and 7-day all-cause mortality rates (hazard ratio 1.05 [95% CI 0.6 to 1.9]) were all similar. CONCLUSIONS Using a conservative 'rate-and-wait' strategy with early follow-up for patients presenting to ED with AF/AFL can safely reduce unnecessary cardioversions and avoidable hospitalisations.
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Affiliation(s)
- Kaleb Addy
- Department of General Medicine, Auckland City Hospital, Auckland, New Zealand
- Department of Surgery and Critical Care, University of Otago, Christchurch, New Zealand
| | - Laura R Joyce
- Department of Surgery and Critical Care, University of Otago, Christchurch, New Zealand
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Ibrahim S Al-Busaidi
- Department of Primary Care and Clinical Simulation, University of Otago, Christchurch, New Zealand
- Department of Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - John W Pickering
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Richard Troughton
- Department of Medicine, University of Otago, Christchurch, New Zealand
- Cardiology Department, Christchurch Hospital, Christchurch, New Zealand
| | - Martin Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
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2
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Gehi AK, Armbruster T, Walker J, Rosman L, Laux J, Becker A, Aladesanmi O, Mazzella AJ, Deyo Z, Biese K. Implementation of an Atrial Fibrillation Decision Aid Care Pathway in the Emergency Department Reduces Atrial Fibrillation Hospitalizations. Circ Cardiovasc Qual Outcomes 2023; 16:e009808. [PMID: 37492958 DOI: 10.1161/circoutcomes.122.009808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 06/27/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND A straightforward decision aid to guide disposition of atrial fibrillation (AF) patients in the emergency department (ED) was developed for use by ED providers. The implementation of this decision aid in the ED has not been studied. METHODS A pragmatic stepped-wedge cluster approach for analysis of retrospectively collected electronic health record data was used in which 5 hospitals were selected to commence the intervention at periodic intervals following an initial 1-year baseline assessment with 5 additional hospitals included in the comparison group (all in North Carolina). The primary end point of analysis was hospitalization rate. Hierarchical multivariable logistic regression analyses for admission as a function of the intervention while controlling for prespecified patient and hospital predictors were performed with clustering done at the hospital level. RESULTS Between October 2017 and May 2020, a total of 11 458 patients (mean age, 71.4; 50.5% female) presented to 1 of the 10 hospitals with a primary diagnosis of AF. Absolute admission rate was reduced from 60.5% to 48.3% following the intervention (odds ratio, 0.83 [95% CI, 0.71-0.97]; P=0.016). After adjusting for covariates, the intervention was associated with a small increased rate of return to the ED for AF within 30 days of the initial presentation (1.6% to 2.7%; hazard ratio, 1.70 [95% CI, 1.26-2.31]; P<0.001). CONCLUSIONS We demonstrate that implementation of a novel decision aid to guide disposition of patients primary diagnosis of AF presenting to the ED was associated with a reduced admission rate independent of patient and hospital factors. Use of the protocol was associated with a small but significant increase in rate of repeat presentations for AF at 30-day follow-up. Use of a decision aid such as the one described here represents an important tool to reduce unnecessary AF hospitalizations.
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Affiliation(s)
- Anil K Gehi
- Department of Medicine, Division of Cardiology, University of North Carolina at Chapel Hill (A.G., T.A., J.W., L.R., A.B., O.A., A.J.M.)
| | - Tiffany Armbruster
- Department of Medicine, Division of Cardiology, University of North Carolina at Chapel Hill (A.G., T.A., J.W., L.R., A.B., O.A., A.J.M.)
| | - Jennifer Walker
- Department of Medicine, Division of Cardiology, University of North Carolina at Chapel Hill (A.G., T.A., J.W., L.R., A.B., O.A., A.J.M.)
| | - Lindsey Rosman
- Department of Medicine, Division of Cardiology, University of North Carolina at Chapel Hill (A.G., T.A., J.W., L.R., A.B., O.A., A.J.M.)
| | - Jeffrey Laux
- University of North Carolina at Chapel Hill Gillings School of Global Public Health (J.L.)
| | - Ari Becker
- Department of Medicine, Division of Cardiology, University of North Carolina at Chapel Hill (A.G., T.A., J.W., L.R., A.B., O.A., A.J.M.)
| | - Oludamilola Aladesanmi
- Department of Medicine, Division of Cardiology, University of North Carolina at Chapel Hill (A.G., T.A., J.W., L.R., A.B., O.A., A.J.M.)
| | - Anthony J Mazzella
- Department of Medicine, Division of Cardiology, University of North Carolina at Chapel Hill (A.G., T.A., J.W., L.R., A.B., O.A., A.J.M.)
| | - Zachariah Deyo
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, Chapel Hill, NC (Z.D.)
| | - Kevin Biese
- Department of Emergency Medicine, University of North Carolina at Chapel Hill (K.B.)
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Leopoulou M, Theofilis P, Kordalis A, Papageorgiou N, Sagris M, Oikonomou E, Tousoulis D. Diabetes mellitus and atrial fibrillation-from pathophysiology to treatment. World J Diabetes 2023; 14:512-527. [PMID: 37273256 PMCID: PMC10236990 DOI: 10.4239/wjd.v14.i5.512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 02/21/2023] [Accepted: 04/07/2023] [Indexed: 05/15/2023] Open
Abstract
Type 2 diabetes mellitus (T2DM) is a leading risk factor for cardiovascular complications around the globe and one of the most common medical conditions. Atrial fibrillation (AF) is the most common supraventricular arrhythmia, with a rapidly increasing prevalence. T2DM has been closely associated with the risk of AF development, identified as an independent risk factor. Regarding cardio-vascular complications, both AF and T2DM have been linked with high mortality. The underlying pathophysiology has not been fully determined yet; however, it is multifactorial, including structural, electrical, and autonomic pathways. Novel therapies include pharmaceutical agents in sodium-glucose cotransporter-2 inhibitors, as well as antiarrhythmic strategies, such as cardioversion and ablation. Of interest, glucose-lowering therapies may affect the prevalence of AF. This review presents the current evidence regarding the connection between the two entities, the pathophysiological pathways that link them, and the therapeutic options that exist.
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Affiliation(s)
- Marianna Leopoulou
- 1st Cardiology Clinic, ‘Hippokration’ General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens 11527, Greece
| | - Panagiotis Theofilis
- 1st Cardiology Clinic, ‘Hippokration’ General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens 11527, Greece
| | - Athanasios Kordalis
- 1st Cardiology Clinic, ‘Hippokration’ General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens 11527, Greece
| | - Nikolaos Papageorgiou
- 1st Cardiology Clinic, ‘Hippokration’ General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens 11527, Greece
| | - Marios Sagris
- 1st Cardiology Clinic, ‘Hippokration’ General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens 11527, Greece
| | - Evangelos Oikonomou
- 3rd Cardiology Clinic, ‘Sotiria’ Chest Diseases Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens 11527, Greece
| | - Dimitris Tousoulis
- 1st Cardiology Clinic, ‘Hippokration’ General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens 11527, Greece
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4
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Shaji EJ, Al-Busaidi IS, Joyce LR, Pickering JW, Troughton RW, Than M. Factors predictive of spontaneous reversion to sinus rhythm: Findings from an integrated acute atrial fibrillation pathway. Heart Rhythm 2023; 20:779-780. [PMID: 36708907 DOI: 10.1016/j.hrthm.2023.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 12/19/2022] [Accepted: 01/17/2023] [Indexed: 01/26/2023]
Affiliation(s)
- Emmanuel J Shaji
- Department of Primary Care and Clinical Simulation, University of Otago, Christchurch, New Zealand; Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Ibrahim S Al-Busaidi
- Department of Primary Care and Clinical Simulation, University of Otago, Christchurch, New Zealand.
| | - Laura R Joyce
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand; Department of Surgery, University of Otago, Christchurch, New Zealand
| | - John W Pickering
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Richard W Troughton
- Department of Medicine, University of Otago, Christchurch, New Zealand; Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Martin Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
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5
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Al-Busaidi IS, Clare GC, Joyce LR, Pearson S, Lainchbury J, Than M, Troughton RW. Presentation, Treatment and Long-Term Outcomes of a Multidisciplinary Acute Atrial Fibrillation Pathway: A 12-Month Follow-Up Study. Heart Lung Circ 2021; 31:216-223. [PMID: 34210615 DOI: 10.1016/j.hlc.2021.05.102] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/01/2021] [Accepted: 05/16/2021] [Indexed: 11/17/2022]
Abstract
AIM Atrial fibrillation/flutter (AF/AFL) is associated with high rates of emergency department (ED) visits and acute hospitalisation. A recently established multidisciplinary acute AF treatment pathway seeks to avoid hospital admissions by early discharge of haemodynamically stable, low risk patients from the ED with next-working-day return to a ward-based AF clinic for further assessment. We conducted a preliminary analysis of the clinical outcomes of this pathway. METHODS We retrospectively reviewed clinical records of all patients assessed at the AF clinic at Christchurch Hospital over a 12-month period. Data related to presentation, patient characteristics, treatment, and 12-month outcomes were analysed. RESULTS A total of 143 patients (median age 65, interquartile range: 57-74 years, 59% male, 87% European) were assessed. Of these, 87 (60.8%) presented with their first episode of AF/AFL. Spontaneous cardioversion occurred in 41% at ED discharge, and this increased to 73% at AF clinic review. Electrical cardioversion was subsequently performed in 16 patients (11.2%), and 16 (11.2%) ultimately required hospital admission (eight to facilitate electrical cardioversion). At a median of 1 day, 83.9% were discharged from the AF clinic in sinus rhythm. During 12-month follow-up, there were 25 AF-related hospitalisations (20 patients, 14%) and one patient underwent electrical cardioversion; additionally, one patient had had a stroke and eight had bleeding complications giving a combined outcome rate of 6.3%. CONCLUSION Utilising a rate-control strategy with ED discharge and early return to a dedicated AF clinic can safely prevent the majority of hospitalisations, avert unnecessary procedures, and facilitate longitudinal care.
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Affiliation(s)
- Ibrahim S Al-Busaidi
- Department of Medicine, University of Otago, Christchurch, New Zealand; Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand.
| | - Geoffrey C Clare
- Department of Medicine, University of Otago, Christchurch, New Zealand; Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Laura R Joyce
- Department of Surgery, University of Otago, Christchurch, New Zealand; Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - Scott Pearson
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - John Lainchbury
- Department of Medicine, University of Otago, Christchurch, New Zealand; Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Martin Than
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - Richard W Troughton
- Department of Medicine, University of Otago, Christchurch, New Zealand; Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
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Pluymaekers NA, Hermans AN, Linz DK, Dudink EA, Luermans JG, Weijs B, Vernooy K, Crijns HJ. Frequency and Determinants of Spontaneous Conversion to Sinus Rhythm in Patients Presenting to the Emergency Department with Recent-onset Atrial Fibrillation: A Systematic Review. Arrhythm Electrophysiol Rev 2021; 9:195-201. [PMID: 33437487 PMCID: PMC7788393 DOI: 10.15420/aer.2020.34] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The exact frequency and clinical determinants of spontaneous conversion (SCV) in patients with symptomatic recent-onset AF are unclear. The aim of this systematic review is to provide an overview of the frequency and determinants of SCV of AF in patients presenting at the emergency department. A comprehensive literature search for studies about SCV in patients presenting to the emergency department with AF resulted in 25 articles - 12 randomised controlled trials and 13 observational studies. SCV rates range between 9-83% and determinants of SCV also varied between studies. The most important determinants of SCV included short duration of AF (<24 or <48 hours), low number of episodes, normal atrial dimensions and absence of previous heart disease. The large variation in SCV rate and determinants of SCV was related to differences in duration of the observation period, inclusion and exclusion criteria and in variables used in the prediction models.
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Affiliation(s)
- Nikki Aha Pluymaekers
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Astrid Nl Hermans
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Dominik K Linz
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands.,Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Elton Amp Dudink
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Justin Glm Luermans
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands.,Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Bob Weijs
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands.,Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Harry Jgm Crijns
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
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Wetterslev M, Granholm A, Haase N, Hassager C, Hylander Møller M, Perner A. Treatment strategies for new-onset atrial fibrillation in critically ill patients: Protocol for a systematic review. Acta Anaesthesiol Scand 2020; 64:1343-1349. [PMID: 32673400 DOI: 10.1111/aas.13672] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 07/12/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND New-onset atrial fibrillation is frequent in critically ill patients and associated with poorer outcomes in these patients. Numerous interventions are used for the management of new-onset atrial fibrillation, but it is unknown if these interventions improve patient-important outcomes as compared with placebo or no active intervention in adult critically ill patients. METHODS/DESIGN We will conduct a systematic review with meta-analysis and trial sequential analysis of randomized clinical trials assessing pharmacological and non-pharmacological interventions of new-onset atrial fibrillation as compared with placebo or no active intervention in adult critically ill patients. The primary outcomes are mortality, adverse events and health-related quality of life. We will search the following databases: MEDLINE, EMBASE, Cochrane Library, ClinicalTrials.gov, Science Citation Index and BIOSIS and follow the recommendations by the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. We will evaluate the overall certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. DISCUSSION New-onset atrial fibrillation is common in adult critically ill patients. However, the balance between the desirable and undesirable effects of pharmacological and non-pharmacological interventions is unknown. The outlined systematic review aims to provide updated data on this topic. REGISTRATION Submitted to PROSPERO (CRD42020187178 ). Status: accepted.
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Affiliation(s)
- Mik Wetterslev
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet, Copenhagen Denmark
| | - Anders Granholm
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet, Copenhagen Denmark
| | - Nicolai Haase
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet, Copenhagen Denmark
| | - Christian Hassager
- Department of Cardiology Copenhagen University Hospital Rigshospitalet, Copenhagen Denmark
| | - Morten Hylander Møller
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet, Copenhagen Denmark
| | - Anders Perner
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet, Copenhagen Denmark
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