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Tsiachris D, Argyriou N, Tsioufis P, Antoniou CK, Laina A, Oikonomou G, Doundoulakis I, Kordalis A, Dimitriadis K, Gatzoulis K, Tsioufis K. Aggressive Rhythm Control Strategy in Atrial Fibrillation Patients Presenting at the Emergency Department: The HEROMEDICUS Study Design and Initial Results. J Cardiovasc Dev Dis 2024; 11:109. [PMID: 38667727 PMCID: PMC11049958 DOI: 10.3390/jcdd11040109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 03/26/2024] [Accepted: 03/26/2024] [Indexed: 04/28/2024] Open
Abstract
Atrial fibrillation has progressively become a more common reason for emergency department visits, representing 0.5% of presenting reasons. Registry data have indicated that about 60% of atrial fibrillation patients who present to the emergency department are admitted, emphasizing the need for more efficient management of atrial fibrillation in the acute phase. Management of atrial fibrillation in the setting of the emergency department varies between countries and healthcare systems. The most plausible reason to justify a conservative rather than an aggressive strategy in the management of atrial fibrillation is the absence of specific guidelines from diverse societies. Several trials of atrial fibrillation treatment strategies, including cardioversion, have demonstrated that atrial fibrillation in the emergency department can be treated safely and effectively, avoiding admission. In the present study, we present the epidemiology and characteristics of atrial fibrillation patients presenting to the emergency department, as well as the impact of diverse management strategies on atrial-fibrillation-related hospital admissions. Lastly, the design and initial data of the HEROMEDICUS protocol will be presented, which constitutes an electrophysiology-based aggressive rhythm control strategy in patients with atrial fibrillation in the emergency department setting.
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Affiliation(s)
- Dimitrios Tsiachris
- First Department of Cardiology, School of Medicine, Hippokration General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (N.A.); (P.T.); (C.K.A.); (A.L.); (G.O.); (A.K.); (K.D.); (K.G.); (K.T.)
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 286] [Impact Index Per Article: 286.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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3
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 95] [Impact Index Per Article: 95.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Adhikari S, Tiwari S, Shakesprere J, Kemper S, Davis E, Carter W. Predictors and timeline of spontaneous conversion to normal sinus rhythm: A single center retrospective cohort study of patients with symptomatic atrial fibrillation. Indian Pacing Electrophysiol J 2023; 23:183-188. [PMID: 37739312 PMCID: PMC10685101 DOI: 10.1016/j.ipej.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 06/01/2023] [Accepted: 09/12/2023] [Indexed: 09/24/2023] Open
Abstract
INTRODUCTION Annual healthcare expenditures associated with atrial fibrillation (AF) in the United States (US) continue to grow as more symptomatic patients present to emergency departments (ED). Predictors of spontaneous conversion to normal sinus rhythm (ScNSR) remain poorly understood, as well as the timeline of ScNSR remains unclear. We sought to 1) to assess the association of key demographics, anthropometric, and clinical factors to ScNSR and 2) to evaluate the timeline of ScNSR, and 3) determine clinical predictors of ScNSR. METHODS This single center, retrospective cohort study analyzed patients aged ≥18 years with symptomatic AF as diagnosed and evaluated through the ED of a rural tertiary care center in West Virginia from September 2015 to December 2018. RESULTS Our cohort consisted of 375 AF patients (mean age 65 years, 54% male). A total of 177 patients attained ScNSR either in the ED or after hospital admission with a mean conversion time of 14.7 h (±12). Onset of symptoms <24 hrs has strong positive association to ScNSR 3.97 (95% CI: 2.24-7.05; p < 0.0001). Male gender 0.55 (95% CI: 0.35-0.85; p = 0.007) and hypertension 0.48 (95% CI: 0.31-0.76; p = 0.002), showed a strong negative association to ScNSR. Of the patients that converted spontaneously (177), the majority, 136 (76.8%) achieved ScNSR within 24 h of ED triage without use of electrical or chemical cardioversion. CONCLUSION Most patients with AF in the ED converted spontaneously to sinus rhythm within the first 24 h which underscores the importance of earlier watchful waiting over interventions to achieve normal sinus rhythm (NSR).
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Affiliation(s)
- Shubash Adhikari
- Charleston Area Medical Center, Department of Cardiology, 3200 MacCorkle Ave SE, Charleston, WV, 25304, USA.
| | - Shabnam Tiwari
- Charleston Area Medical Center, 3200 MacCorkle Ave SE, Charleston, WV, 25304, USA
| | - Jonathan Shakesprere
- West Virginia University, School of Medicine, 1 Medical Center Drive, Morgantown, WV, 26506, USA
| | - Suzanne Kemper
- CAMC Health Education and Research Institute, 3110 MacCorkle Ave SE, Charleston, WV, 25304, USA
| | - Elaine Davis
- CAMC Health Education and Research Institute, 3110 MacCorkle Ave SE, Charleston, WV, 25304, USA
| | - William Carter
- CAMC Health Education and Research Institute, 3110 MacCorkle Ave SE, Charleston, WV, 25304, USA
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Demirel O, Berezin AE, Mirna M, Boxhammer E, Gharibeh SX, Hoppe UC, Lichtenauer M. Biomarkers of Atrial Fibrillation Recurrence in Patients with Paroxysmal or Persistent Atrial Fibrillation Following External Direct Current Electrical Cardioversion. Biomedicines 2023; 11:1452. [PMID: 37239123 PMCID: PMC10216298 DOI: 10.3390/biomedicines11051452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 04/25/2023] [Accepted: 04/25/2023] [Indexed: 05/28/2023] Open
Abstract
Atrial fibrillation (AF) is associated with atrial remodeling, cardiac dysfunction, and poor clinical outcomes. External direct current electrical cardioversion is a well-developed urgent treatment strategy for patients presenting with recent-onset AF. However, there is a lack of accurate predictive serum biomarkers to identify the risks of AF relapse after electrical cardioversion. We reviewed the currently available data and interpreted the findings of several studies revealing biomarkers for crucial elements in the pathogenesis of AF and affecting cardiac remodeling, fibrosis, inflammation, endothelial dysfunction, oxidative stress, adipose tissue dysfunction, myopathy, and mitochondrial dysfunction. Although there is ample strong evidence that elevated levels of numerous biomarkers (such as natriuretic peptides, C-reactive protein, galectin-3, soluble suppressor tumorigenicity-2, fibroblast growth factor-23, turn-over collagen biomarkers, growth differential factor-15) are associated with AF occurrence, the data obtained in clinical studies seem to be controversial in terms of their predictive ability for post-cardioversion outcomes. Novel circulating biomarkers are needed to elucidate the modality of this approach compared with conventional predictive tools. Conclusions: Biomarker-based strategies for predicting events after AF treatment require extensive investigation in the future, especially in the presence of different gender and variable comorbidity profiles. Perhaps, a multiple biomarker approach exerts more utilization for patients with different forms of AF than single biomarker use.
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Affiliation(s)
- Ozan Demirel
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria; (O.D.); (M.M.); (E.B.); (S.X.G.); (U.C.H.); (M.L.)
| | - Alexander E. Berezin
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria; (O.D.); (M.M.); (E.B.); (S.X.G.); (U.C.H.); (M.L.)
- Internal Medicine Department, Zaporozhye State Medical University, 69035 Zaporozhye, Ukraine
| | - Moritz Mirna
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria; (O.D.); (M.M.); (E.B.); (S.X.G.); (U.C.H.); (M.L.)
| | - Elke Boxhammer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria; (O.D.); (M.M.); (E.B.); (S.X.G.); (U.C.H.); (M.L.)
| | - Sarah X. Gharibeh
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria; (O.D.); (M.M.); (E.B.); (S.X.G.); (U.C.H.); (M.L.)
| | - Uta C. Hoppe
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria; (O.D.); (M.M.); (E.B.); (S.X.G.); (U.C.H.); (M.L.)
| | - Michael Lichtenauer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria; (O.D.); (M.M.); (E.B.); (S.X.G.); (U.C.H.); (M.L.)
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Chyou JY, Barkoudah E, Dukes JW, Goldstein LB, Joglar JA, Lee AM, Lubitz SA, Marill KA, Sneed KB, Streur MM, Wong GC, Gopinathannair R. Atrial Fibrillation Occurring During Acute Hospitalization: A Scientific Statement From the American Heart Association. Circulation 2023; 147:e676-e698. [PMID: 36912134 DOI: 10.1161/cir.0000000000001133] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
Acute atrial fibrillation is defined as atrial fibrillation detected in the setting of acute care or acute illness; atrial fibrillation may be detected or managed for the first time during acute hospitalization for another condition. Atrial fibrillation after cardiothoracic surgery is a distinct type of acute atrial fibrillation. Acute atrial fibrillation is associated with high risk of long-term atrial fibrillation recurrence, warranting clinical attention during acute hospitalization and over long-term follow-up. A framework of substrates and triggers can be useful for evaluating and managing acute atrial fibrillation. Acute management requires a multipronged approach with interdisciplinary care collaboration, tailoring treatments to the patient's underlying substrate and acute condition. Key components of acute management include identification and treatment of triggers, selection and implementation of rate/rhythm control, and management of anticoagulation. Acute rate or rhythm control strategy should be individualized with consideration of the patient's capacity to tolerate rapid rates or atrioventricular dyssynchrony, and the patient's ability to tolerate the risk of the therapeutic strategy. Given the high risks of atrial fibrillation recurrence in patients with acute atrial fibrillation, clinical follow-up and heart rhythm monitoring are warranted. Long-term management is guided by patient substrate, with implications for intensity of heart rhythm monitoring, anticoagulation, and considerations for rhythm management strategies. Overall management of acute atrial fibrillation addresses substrates and triggers. The 3As of acute management are acute triggers, atrial fibrillation rate/rhythm management, and anticoagulation. The 2As and 2Ms of long-term management include monitoring of heart rhythm and modification of lifestyle and risk factors, in addition to considerations for atrial fibrillation rate/rhythm management and anticoagulation. Several gaps in knowledge related to acute atrial fibrillation exist and warrant future research.
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7
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Nguyen ST, Belley-Côté EP, Ibrahim O, Um KJ, Lengyel A, Adli T, Qiu Y, Wong M, Sibilio S, Benz AP, Wolf A, Whitlock NJ, Gabriel Acosta J, Healey JS, Baranchuk A, McIntyre WF. Techniques improving electrical cardioversion success for patients with atrial fibrillation: a systematic review and meta-analysis. Europace 2022; 25:318-330. [PMID: 36503970 PMCID: PMC9935008 DOI: 10.1093/europace/euac199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/13/2022] [Indexed: 12/14/2022] Open
Abstract
AIMS Electrical cardioversion is commonly used to restore sinus rhythm in patients with atrial fibrillation (AF), but procedural technique and clinical success vary. We sought to identify techniques associated with electrical cardioversion success for AF patients. METHODS AND RESULTS We searched MEDLINE, EMBASE, CENTRAL, and the grey literature from inception to October 2022. We abstracted data on initial and cumulative cardioversion success. We pooled data using random-effects models. From 15 207 citations, we identified 45 randomized trials and 16 observational studies. In randomized trials, biphasic when compared with monophasic waveforms resulted in higher rates of initial [16 trials, risk ratio (RR) 1.71, 95% CI 1.29-2.28] and cumulative success (18 trials, RR 1.10, 95% CI 1.04-1.16). Fixed, high-energy (≥200 J) shocks when compared with escalating energy resulted in a higher rate of initial success (four trials, RR 1.62, 95% CI 1.33-1.98). Manual pressure when compared with no pressure resulted in higher rates of initial (two trials, RR 2.19, 95% CI 1.21-3.95) and cumulative success (two trials, RR 1.19, 95% CI 1.06-1.34). Cardioversion success did not differ significantly for other interventions, including: antero-apical/lateral vs. antero-posterior positioned pads (initial: 11 trials, RR 1.16, 95% CI 0.97-1.39; cumulative: 14 trials, RR 1.01, 95% CI 0.96-1.06); rectilinear/pulsed biphasic vs. biphasic truncated exponential waveform (initial: four trials, RR 1.11, 95% CI 0.91-1.34; cumulative: four trials, RR 0.98, 95% CI 0.89-1.08) and cathodal vs. anodal configuration (cumulative: two trials, RR 0.99, 95% CI 0.92-1.07). CONCLUSIONS Biphasic waveforms, high-energy shocks, and manual pressure increase the success of electrical cardioversion for AF. Other interventions, especially pad positioning, require further study.
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Affiliation(s)
- Stephanie T Nguyen
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada,Department of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada
| | - Emilie P Belley-Côté
- Department of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada,Population Health Research Institute, McMaster University, Hamilton, Ontario L8L 2X2, Canada
| | - Omar Ibrahim
- Department of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada
| | - Kevin J Um
- Department of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada
| | - Alexandra Lengyel
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada
| | - Taranah Adli
- Schulich School of Medicine and Dentistry, Western University, London, Ontario N6A 5C1, Canada
| | - Yuan Qiu
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada,University of Ottawa, Ottawa, Ontario K1N 6N5, Canada
| | - Michael Wong
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada
| | - Serena Sibilio
- Istituto Clinico Sant’Ambrogio, Università di Milano, Milano 20157, Italy
| | - Alexander P Benz
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg-University, Mainz 55131, Germany
| | - Alex Wolf
- University of Limerick School of Medicine, Limerick V94 T9PX, Ireland
| | - Nicola J Whitlock
- Bishop Tonnos Catholic Secondary School, Ancaster, Ontario L9G 5E3, Canada
| | - Juan Gabriel Acosta
- Department of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada
| | - Jeff S Healey
- Department of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada,Population Health Research Institute, McMaster University, Hamilton, Ontario L8L 2X2, Canada
| | - Adrian Baranchuk
- Queen’s University School of Medicine, Queen’s University, Kingston, Ontario K7L 3L4, Canada
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From Bench to Bedside—Implementing the New ABC Approach for Atrial Fibrillation in an Emergency Department Setting. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19084797. [PMID: 35457664 PMCID: PMC9031451 DOI: 10.3390/ijerph19084797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 04/13/2022] [Indexed: 02/01/2023]
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9
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Implementation of a Procainamide-Based Cardioversion Strategy for the Management of Recent-Onset Atrial Fibrillation. Adv Emerg Nurs J 2021; 43:186-193. [PMID: 34397493 DOI: 10.1097/tme.0000000000000358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Atrial fibrillation/flutter (AF) remains the most common rhythm disturbance in adult patients presenting to emergency departments (EDs). Although pharmacologic cardioversion has been established as safe and effective in recent-onset AF, its use in U.S. EDs is uncommon. The purpose of this study was to assess the safety and efficacy of intravenous (IV) procainamide for pharmacologic cardioversion in patients presenting to the ED with AF of <48-hr duration. Patients presenting to the ED with recent-onset AF (<48 hr) undergoing a cardioversion strategy with IV procainamide from 2017 to 2019 were reviewed. Clinical outcomes assessed included rates of cardioversion, hospital admission, stroke, and return ED visits for arrhythmia or serious adverse events. A total of 64 patients received procainamide therapy-60.9% achieved cardioversion and 35.9% were admitted to the hospital. The mean dose was 1062.4 mg (12.1 mg/kg). No patients returned to the ED secondary to stroke and 9.4% experienced complications attributed to procainamide, the most common being hypotension. Within 30 days of therapy, 20.3% of patients returned to the ED secondary to arrhythmia recurrence. Patients experiencing cardioversion with procainamide were less likely to be admitted to the hospital (25.6% vs. 52.0%; p = 0.04) or receive a rate control agent (17.9% vs. 64.0%; p = 0.001). There was no significant difference in the rate of 30-day return between those who experienced pharmacologic cardioversion and those who did not (p = 0.220). The implementation of a procainamide-based acute cardioversion strategy for patients presenting to the ED with recent-onset AF resulted in a 60% cardioversion rate, which was associated with a significantly higher rate of discharge from the ED. Transient hypotension was the most common adverse event. Further investigation into ED-based protocols for management of recent-onset AF is necessary to better understand their safety and efficacy.
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10
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Zaro B, Alpert EA, Kaufman N, Rosenmann D. Outcomes of transesophageal echocardiogram-guided electrical cardioversion in patients with atrial fibrillation greater than 48 hours treated in the emergency department versus the cardiology ward: A retrospective comparison study. Int J Clin Pract 2021; 75:e14480. [PMID: 34107147 DOI: 10.1111/ijcp.14480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 05/24/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The current emergency medicine literature on cardioversion for atrial fibrillation (AF) describes its performance on those who are hemodynamically unstable, present within 48 hours of the onset of the arrhythmia, or are on long-term anticoagulants. For patients who are not anticoagulated and present with atrial fibrillation for more than 48 hours, one option is to perform a transesophageal echocardiogram and then synchronized cardioversion in the absence of atrial clot. The objective of this study is to compare outcomes of patients presenting to the emergency department (ED) with atrial fibrillation (AF) of more than 48 hours who underwent a transesophageal echocardiogram (TEE) and subsequent cardioversion in the ED versus the cardiology ward. METHODS This was a retrospective comparison study of patients who presented to the ED with AF for more than 48 hours, underwent a transesophageal echocardiogram, and then were electrically cardioverted either in the emergency department or in the cardiology ward. Outcomes include: time to cardioversion, length of hospital stay, rate of successful cardioversion, and rate of complications. RESULTS Electrical cardioversion was performed in the ED on 94 patients (62%) and the cardiology ward on 57 (38%). Over 90% of cardioversions were successful in both groups. Time to cardioversion was significantly less in the ED group versus the cardiology group (1.04 ± 0.9 days versus 3.81 ± 1.9; P < .001). Similarly, the mean length of hospital stay was less for the ED group (1.6 ± 1.6 days versus 7.3 ± 3.5; P < .001). CONCLUSION Patients who present in atrial fibrillation for more than 48 hours and then have a TEE undergo electrical cardioversion faster in the ED compared with the cardiology ward. This clinical pathway also results in a shorter length of hospital stay without having more side effects.
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Affiliation(s)
- Baha Zaro
- Department of Emergency Medicine, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Evan Avraham Alpert
- Department of Emergency Medicine, Shaare Zedek Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Nechama Kaufman
- Department of Quality and Safety, Shaare Zedek Medical Center, Jerusalem, Israel
| | - David Rosenmann
- Jesselson Integrated Heart Centre, Shaare Zedek Medical Center, Jerusalem, Israel
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11
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Wong BM, Perry JJ, Cheng W, Zheng B, Guo K, Taljaard M, Skanes AC, Stiell IG. Thromboembolic events following cardioversion of acute atrial fibrillation and flutter: a systematic review and meta-analysis. CAN J EMERG MED 2021; 23:500-511. [PMID: 33715143 DOI: 10.1007/s43678-021-00103-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 02/09/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Recent studies have presented concerning data on the safety of cardioversion for acute atrial fibrillation and flutter. We conducted this meta-analysis to evaluate the effect of oral anticoagulation use on thromboembolic events post-cardioversion of low-risk acute atrial fibrillation and flutter patients of < 48 h in duration. METHODS We searched MEDLINE, Embase, and Cochrane from inception through February 6, 2020 for studies reporting thromboembolic events post-cardioversion of acute atrial fibrillation and flutter. Main outcome was thromboembolic events within 30 days post-cardioversion. Primary analysis compared thromboembolic events based on oral anticoagulation use versus no oral anticoagulation use. Secondary analysis was based on baseline thromboembolic risk. We performed meta-analyses where 2 or more studies were available, by applying the DerSimonian-Laird random-effects model. Risk of bias was assessed with the Quality in Prognostic Studies tool. RESULTS Of 717 titles screened, 20 studies met inclusion criteria. Primary analysis of seven studies with low risk of bias demonstrated insufficient evidence regarding the risk of thromboembolic events associated with oral anticoagulation use (RR = 0.82 where RR < 1 suggests decreased risk with oral anticoagulation use; 95% CI 0.27 to 2.47; I2 = 0%). Secondary analysis of 13 studies revealed increased risk of thromboembolic events with high baseline thromboembolic risk (RR = 2.25 where RR > 1 indicates increased risk with higher CHADS2 or CHA2DS2-VASc scores; 95% CI 1.25 to 4.04; I2 = 0%). CONCLUSION Primary analysis revealed insufficient evidence regarding the effect of oral anticoagulation use on thromboembolic events post-cardioversion of low-risk acute atrial fibrillation and flutter, though the event rate is low in contemporary practice. Our findings can better inform patient-centered decision-making when considering 4-week oral anticoagulation use for acute atrial fibrillation and flutter patients.
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Affiliation(s)
- Brenton M Wong
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Wei Cheng
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Bo Zheng
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Kevin Guo
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Allan C Skanes
- Division of Cardiology, Western University, London, ON, Canada
| | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
- Clinical Epidemiology Unit, The Ottawa Hospital, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada.
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Andrade JG, Aguilar M, Atzema C, Bell A, Cairns JA, Cheung CC, Cox JL, Dorian P, Gladstone DJ, Healey JS, Khairy P, Leblanc K, McMurtry MS, Mitchell LB, Nair GM, Nattel S, Parkash R, Pilote L, Sandhu RK, Sarrazin JF, Sharma M, Skanes AC, Talajic M, Tsang TSM, Verma A, Verma S, Whitlock R, Wyse DG, Macle L. The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation. Can J Cardiol 2020; 36:1847-1948. [PMID: 33191198 DOI: 10.1016/j.cjca.2020.09.001] [Citation(s) in RCA: 327] [Impact Index Per Article: 81.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/05/2020] [Accepted: 09/05/2020] [Indexed: 12/20/2022] Open
Abstract
The Canadian Cardiovascular Society (CCS) atrial fibrillation (AF) guidelines program was developed to aid clinicians in the management of these complex patients, as well as to provide direction to policy makers and health care systems regarding related issues. The most recent comprehensive CCS AF guidelines update was published in 2010. Since then, periodic updates were published dealing with rapidly changing areas. However, since 2010 a large number of developments had accumulated in a wide range of areas, motivating the committee to complete a thorough guideline review. The 2020 iteration of the CCS AF guidelines represents a comprehensive renewal that integrates, updates, and replaces the past decade of guidelines, recommendations, and practical tips. It is intended to be used by practicing clinicians across all disciplines who care for patients with AF. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to evaluate recommendation strength and the quality of evidence. Areas of focus include: AF classification and definitions, epidemiology, pathophysiology, clinical evaluation, screening and opportunistic AF detection, detection and management of modifiable risk factors, integrated approach to AF management, stroke prevention, arrhythmia management, sex differences, and AF in special populations. Extensive use is made of tables and figures to synthesize important material and present key concepts. This document should be an important aid for knowledge translation and a tool to help improve clinical management of this important and challenging arrhythmia.
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Affiliation(s)
- Jason G Andrade
- University of British Columbia, Vancouver, British Columbia, Canada; Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada.
| | - Martin Aguilar
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Alan Bell
- University of Toronto, Toronto, Ontario, Canada
| | - John A Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Jafna L Cox
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - Paul Dorian
- University of Toronto, Toronto, Ontario, Canada
| | | | | | - Paul Khairy
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | | | - Girish M Nair
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Stanley Nattel
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | | | - Jean-François Sarrazin
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | - Mukul Sharma
- McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada
| | | | - Mario Talajic
- Montreal Heart Institute, University of Montreal, Montréal, Quebec, Canada
| | - Teresa S M Tsang
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Laurent Macle
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
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The Canadian Cardiovascular Society 2018 guideline update for atrial fibrillation - A different perspective. CAN J EMERG MED 2020; 21:572-575. [PMID: 31551100 DOI: 10.1017/cem.2019.399] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Paroxysmal atrial fibrillation: changes in factor VIII and von Willebrand factor impose early hypercoagulability. ACTA ACUST UNITED AC 2020; 5:e140-e147. [PMID: 32832713 PMCID: PMC7433786 DOI: 10.5114/amsad.2020.97101] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 05/23/2020] [Indexed: 12/22/2022]
Abstract
Introduction Paroxysmal atrial fibrillation (PAF) is a well-documented prothrombotic state that carries significant embolic risk. However, precise hemostatic changes in the very early stage of the disease are not completely studied. The aim of the study was to study von Willebrand factor (vWF) and coagulation factor VIII (FVIII) plasma levels and activity in the first hours (up to 24 h) of PAF clinical manifestation. Material and methods We selected consecutively 51 non-anticoagulated patients (26 men, 25 women, mean age: 59.84 ±1.60) with PAF and 52 controls (26 men, 26 women, mean age: 59.50 ±1.46 years) corresponding in gender, accompanying diseases and conducted treatment. The indicators were examined using enzyme-linked immunoassays and photometric tests. Results All patients were hospitalized between the 2nd and 24th h after the onset of arrhythmia (mean: 8.14 ±0.74 h). Higher FVIII levels (107.52 ±3.48% vs. 93.85 ±2.93%, p < 0.05) and activity (200.03 ±11.11% vs. 109.73 ±4.90%, p < 0.001) were found in the PAF group. vWF levels (178.40 ±12.95% vs. 119.53 ±6.12%, p < 0.001) and activity (200.92 ±12.45% vs. 110.80 ±5.14%, p < 0.001) were also higher. These changes did not depend on age, sex, body mass index or CHA2DS2-VASc score in the PAF group (p > 0.05). PAF duration was a significant predictor of increased FVIII levels and activity. Increased PAF duration was followed by increased values of the factors (r = 0.85, p < 0.001; r = 0.83, p < 0.001). Conclusions The results presented an activated coagulation cascade and endothelial injury, suggesting hypercoagulability still in the early hours of PAF. These changes in PAF did not correlate with CHA2DS2-VASc score risk factors, outlining PAF as a possible independent embolic risk factor.
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Stiell IG, Sivilotti MLA, Taljaard M, Birnie D, Vadeboncoeur A, Hohl CM, McRae AD, Rowe BH, Brison RJ, Thiruganasambandamoorthy V, Macle L, Borgundvaag B, Morris J, Mercier E, Clement CM, Brinkhurst J, Sheehan C, Brown E, Nemnom MJ, Wells GA, Perry JJ. Electrical versus pharmacological cardioversion for emergency department patients with acute atrial fibrillation (RAFF2): a partial factorial randomised trial. Lancet 2020; 395:339-349. [PMID: 32007169 DOI: 10.1016/s0140-6736(19)32994-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/28/2019] [Accepted: 11/22/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Acute atrial fibrillation is the most common arrythmia treated in the emergency department. Our primary aim was to compare conversion to sinus rhythm between pharmacological cardioversion followed by electrical cardioversion (drug-shock), and electrical cardioversion alone (shock-only). Our secondary aim was to compare the effectiveness of two pad positions for electrical cardioversion. METHODS We did a partial factorial trial of two protocols for patients with acute atrial fibrillation at 11 academic hospital emergency departments in Canada. We enrolled adult patients with acute atrial fibrillation. Protocol 1 was a randomised, blinded, placebo-controlled comparison of attempted pharmacological cardioversion with intravenous procainamide (15 mg/kg over 30 min) followed by electrical cardioversion if necessary (up to three shocks, each of ≥200 J), and placebo infusion followed by electrical cardioversion. For patients having electrical cardioversion, we used Protocol 2, a randomised, open-label, nested comparison of anteroposterior versus anterolateral pad positions. Patients were randomly assigned (1:1, stratified by study site) for Protocol 1 by on-site research personnel using an online electronic data capture system. Randomisation for Protocol 2 occurred 30 min after drug infusion for patients who had not converted and was stratified by site and Protocol 1 allocation. Patients and all research and emergency department staff were masked to treatment allocation for Protocol 1. The primary outcome was conversion to normal sinus rhythm for at least 30 min at any time after randomisation and up to a point immediately after three shocks. Protocol 1 was analysed by intention to treat and Protocol 2 excluded patients who did not receive electrical cardioversion. This study is registered at ClinicalTrials.gov, number NCT01891058. FINDINGS Between July 18, 2013, and Oct 17, 2018, we enrolled 396 patients, and none were lost to follow-up. In the drug-shock group (n=204), conversion to sinus rhythm occurred in 196 (96%) patients and in the shock-only group (n=192), conversion occurred in 176 (92%) patients (absolute difference 4%; 95% CI 0-9; p=0·07). The proportion of patients discharged home was 97% (n=198) versus 95% (n=183; p=0·60). 106 (52%) patients in the drug-shock group converted after drug infusion only. No patients had serious adverse events in follow-up. The different pad positions in Protocol 2 (n=244), had similar conversions to sinus rhythm (119 [94%] of 127 in anterolateral group vs 108 [92%] of 117 in anteroposterior group; p=0·68). INTERPRETATION Both the drug-shock and shock-only strategies were highly effective, rapid, and safe in restoring sinus rhythm for patients in the emergency department with acute atrial fibrillation, avoiding the need for return to hospital. The drug infusion worked for about half of patients and avoided the resource intensive procedural sedation required for electrical cardioversion. We also found no significant difference between the anterolateral and anteroposterior pad positions for electrical cardioversion. Immediate rhythm control for patients in the emergency department with acute atrial fibrillation leads to excellent outcomes. FUNDING Heart and Stroke Foundation of Canada and the Canadian Institutes of Health Research.
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Affiliation(s)
- Ian G Stiell
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.
| | | | - Monica Taljaard
- Clinical Epidemiology Program, School of Epidemiology and Public Health, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - David Birnie
- Division of Cardiology, University of Ottawa, Ottawa, ON, Canada
| | - Alain Vadeboncoeur
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, QC, Canada
| | - Corinne M Hohl
- Department of Emergency Medicine, Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Brian H Rowe
- Department of Emergency Medicine, and School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Robert J Brison
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
| | | | - Laurent Macle
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, QC, Canada
| | - Bjug Borgundvaag
- Division of Emergency Medicine, University of Toronto, Schwartz/Reisman Emergency Medicine Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | - Judy Morris
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montréal, QC, Canada
| | - Eric Mercier
- Department of Family Medicine and Emergency Medicine, Centre de Recherche du CHU de Québec, Université Laval, Québec, QC, Canada
| | - Catherine M Clement
- Clinical Epidemiology Program, School of Epidemiology and Public Health, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Jennifer Brinkhurst
- Clinical Epidemiology Program, School of Epidemiology and Public Health, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Connor Sheehan
- Clinical Epidemiology Program, School of Epidemiology and Public Health, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Erica Brown
- Clinical Epidemiology Program, School of Epidemiology and Public Health, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Marie-Joe Nemnom
- Clinical Epidemiology Program, School of Epidemiology and Public Health, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - George A Wells
- University of Ottawa Heart Institute, University of Ottawa, Ottawa, ON, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
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Botto GL, Tortora G. Is delayed cardioversion the better approach in recent-onset atrial fibrillation? Yes. Intern Emerg Med 2020; 15:1-4. [PMID: 31834587 DOI: 10.1007/s11739-019-02225-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 10/23/2019] [Indexed: 01/09/2023]
Abstract
Atrial fibrillation is the most common sustained arrhythmia encountered in primary care practice and represents a significant burden on the health care system with a higher than expected hospitalization rate from the emergency department. The first goal of therapy is to assess the patient's symptoms and hemodynamic status. There are multiple acute management strategies for atrial fibrillation including heart rate control, immediate direct-current cardioversion, or pharmacologic cardioversion. Given the variety of approaches to acute atrial fibrillation, it is often difficult to consistently provide cost-effectiveness care. The likelihood of spontaneous conversion of acute atrial fibrillation to sinus rhythm is reported to be really high. Although active cardioversion of recent-onset atrial fibrillation is generally considered to be safe, the question arises of whether the strategy of immediate treatment for a condition that is likely to resolve spontaneously is acceptable for hemodynamically stable patients. Based on published data, non-managed acute treatment of atrial fibrillation appears to be cost-saving. The observation of a patient with recent-onset atrial fibrillation in a dedicated unit within the emergency department reduces the need for acute cardioversion in almost two-thirds of the patients, and reduces the median length of stay, without negatively affecting long-term outcome, thus reducing the related health care costs. However, to let these results broadly applicable, defined treatment algorithms and access to prompt follow-up are needed, which may not be practical in all settings.
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Affiliation(s)
- Giovanni Luca Botto
- Department of Electrophysiology and Clinical Arrhythmology, ASST Rhodense, Rho and Garbagnate M.se Hospitals, C.so Europa 250, Rho, 20017, Milan, Italy.
| | - Giovanni Tortora
- Department of Electrophysiology and Clinical Arrhythmology, ASST Rhodense, Rho and Garbagnate M.se Hospitals, C.so Europa 250, Rho, 20017, Milan, Italy
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Andrade JG, Mitchell LB. Periprocedural Anticoagulation for Cardioversion of Acute Onset Atrial Fibrillation and Flutter: Evidence Base for Current Guidelines. Can J Cardiol 2019; 35:1301-1310. [DOI: 10.1016/j.cjca.2019.06.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 06/05/2019] [Accepted: 06/05/2019] [Indexed: 11/26/2022] Open
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Andrade JG, Verma A, Mitchell LB, Parkash R, Leblanc K, Atzema C, Healey JS, Bell A, Cairns J, Connolly S, Cox J, Dorian P, Gladstone D, McMurtry MS, Nair GM, Pilote L, Sarrazin JF, Sharma M, Skanes A, Talajic M, Tsang T, Verma S, Wyse DG, Nattel S, Macle L. 2018 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation. Can J Cardiol 2019; 34:1371-1392. [PMID: 30404743 DOI: 10.1016/j.cjca.2018.08.026] [Citation(s) in RCA: 173] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 08/14/2018] [Accepted: 08/15/2018] [Indexed: 11/19/2022] Open
Abstract
The Canadian Cardiovascular Society (CCS) Atrial Fibrillation Guidelines Committee provides periodic reviews of new data to produce focused updates that address clinically important advances in atrial fibrillation (AF) management. This 2018 Focused Update addresses: (1) anticoagulation in the context of cardioversion of AF; (2) the management of antithrombotic therapy for patients with AF in the context of coronary artery disease; (3) investigation and management of subclinical AF; (4) the use of antidotes for the reversal of non-vitamin K antagonist oral anticoagulants; (5) acute pharmacological cardioversion of AF; (6) catheter ablation for AF, including patients with concomitant AF and heart failure; and (7) an integrated approach to the patient with AF and modifiable cardiovascular risk factors. The recommendations were developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) standards. Individual studies and literature were reviewed for quality and bias; the literature review process and evidence tables are included as Supplementary Material and are available on the CCS Web site. Details of the updated recommendations are presented, along with their background and rationale. This document is linked to an updated summary of all CCS AF guidelines recommendations, from 2010 to the present 2018 Focused Update, which is provided in the Supplementary Material.
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Affiliation(s)
- Jason G Andrade
- University of British Columbia, Vancouver, British Columbia, Canada; Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Atul Verma
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - L Brent Mitchell
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Ratika Parkash
- QEII Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kori Leblanc
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Clare Atzema
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Jeff S Healey
- McMaster University, Hamilton, Ontario, Canada; Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Alan Bell
- University of Toronto, Toronto, Ontario, Canada
| | - John Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Stuart Connolly
- McMaster University, Hamilton, Ontario, Canada; Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Jafna Cox
- QEII Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Paul Dorian
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - David Gladstone
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - M Sean McMurtry
- University of Alberta, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Girish M Nair
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Louise Pilote
- McGill University Health Centre, Montréal, Quebec, Canada
| | | | - Mike Sharma
- McMaster University, Hamilton, Ontario, Canada; Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Allan Skanes
- London Heart Institute, Western University, London, Ontario, Canada
| | - Mario Talajic
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Teresa Tsang
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Subodh Verma
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - D George Wyse
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Stanley Nattel
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Laurent Macle
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
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Stiell IG, McMurtry MS, McRae A, Parkash R, Scheuermeyer F, Atzema CL, Skanes A. Safe Cardioversion for Patients With Acute-Onset Atrial Fibrillation and Flutter: Practical Concerns and Considerations. Can J Cardiol 2019; 35:1296-1300. [PMID: 31495687 DOI: 10.1016/j.cjca.2019.06.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 06/05/2019] [Accepted: 06/05/2019] [Indexed: 01/13/2023] Open
Abstract
In this Viewpoint concerns raised by Canadian emergency physicians regarding recommendations 2 and 6 from the recent Canadian Cardiovascular Society 2018 update for atrial fibrillation are discussed. These recommendations narrow the window for safe cardioversion and suggest 4 weeks of anticoagulation for all patients who undergo urgent cardioversion regardless of their CHADS-65 status. We discuss the implications of Grading of Recommendations, Assessment, Development, and Evaluation weak recommendations on the basis of low-quality evidence.
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Affiliation(s)
- Ian G Stiell
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
| | - M Sean McMurtry
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew McRae
- Departments of Emergency Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Ratika Parkash
- Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Frank Scheuermeyer
- Department of Emergency Medicine, University of British Columbia, Center for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Clare L Atzema
- Division of Emergency Medicine, University of Toronto, Sunnybrook Health Sciences Centre, and Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
| | - Allan Skanes
- Division of Cardiology, Western University, London, Ontario, Canada
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Bonfanti L, Annovi A, Sanchis-Gomar F, Saccenti C, Meschi T, Ticinesi A, Cervellin G. Effectiveness and safety of electrical cardioversion for acute-onset atrial fibrillation in the emergency department: a real-world 10-year single center experience. Clin Exp Emerg Med 2019; 6:64-69. [PMID: 30944291 PMCID: PMC6453693 DOI: 10.15441/ceem.17.286] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 03/04/2018] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE Despite limited evidence, electrical cardioversion of acute-onset atrial fibrillation (AAF) is widely performed in the emergency department (ED). The aim of this study was to describe the effectiveness and safety of electrical cardioversion of AAF performed by emergency physicians in the ED. METHODS All episodes of AAF electrically cardioverted in the ED were retrieved from the database for a 10-year period. Most patients not already receiving anticoagulants were given enoxaparin before the procedure (259/419). Procedural complications were recorded, and the patients were followed-up for 30 days for cardiovascular and hemorrhagic complications. RESULTS Four hundred nineteen eligible cases were identified; men represented 69%, and mean age was 61±13 years. The procedure was effective in 403 cases (96.2%; 95.4% in women, 96.5% in men), with considerable differences with respect to the age of the patients, the procedure being effective in 100% of patients aged 18 to 39 and only 68.8% in those >80 years. New ED visits (33/419) were identified within 30 days (31 due to atrial fibrillation/atrial flutter recurrence, 1 due to iatrogenic hypokalemia, 1 due to hypertensive emergency). No strokes, major bleeding, life-threatening arrhythmias or peripheral thromboembolism were recorded. Nine small and mild skin burns were observed. CONCLUSION Electrical cardioversion is an effective and safe procedure in the vast majority of patients, albeit less effective in patients aged >80 years. It appears reasonable to avoid anticoagulation in low-risk patients with AAF and administer peri-procedural heparin to all remaining patients. Long-term anticoagulation should be planned on an individual basis, after assessment of thromboembolic and hemorrhagic risk.
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Affiliation(s)
- Laura Bonfanti
- Emergency Department, University Hospital of Parma, Parma, Italy
| | | | - Fabian Sanchis-Gomar
- Department of Physiology, Faculty of Medicine, University of Valencia and Fundación Investigación Hospital Clínico Universitario de Valencia, Instituto de Investigación INCLIVA, Valencia, Spain.,Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, NY, USA
| | | | - Tiziana Meschi
- Postgraduate Emergency Medicine School, University of Parma, Parma, Italy
| | - Andrea Ticinesi
- Postgraduate Emergency Medicine School, University of Parma, Parma, Italy
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Jaakkola S, Kiviniemi TO, Airaksinen KEJ. Cardioversion for atrial fibrillation - how to prevent thromboembolic complications? Ann Med 2018; 50:549-555. [PMID: 30207497 DOI: 10.1080/07853890.2018.1523552] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Cardioversion is an essential component of rhythm control strategy for atrial fibrillation. The thromboembolic risk of cardioversion is well established and the mechanisms behind the phenomenon have been comprehensively described. There are several clinical aspects that are important to take into consideration when assessing the safety of cardioversion. Before proceeding to cardioversion, the probability of early treatment failure and antiarrhythmic treatment options to prevent recurrences should be carefully evaluated to avoid the risks of repeated futile cardioversions. Effective periprocedural anticoagulation is the mainstay in thromboembolic complication prevention and the first week after rhythm conversion is the most vulnerable period in this respect. Early timing of cardioversion appears to be another important measure to decrease the risk of thromboembolic complications. Transoesophageal echocardiography is useful in clinical scenarios where early cardioversion is desirable due to debilitating clinical symptoms and a short duration of arrhythmia or the adequacy of preceding anticoagulation is uncertain. However, it does not lessen the need for effective anticoagulation after cardioversion. This review summarizes the recent scientific discoveries to improve the safety of cardioversion for atrial fibrillation. Key messages Cardioversion for atrial fibrillation entails a significant risk of thromboembolic complications, especially during the first week after the procedure. The intensity of periprocedural anticoagulation and the timing of cardioversion appear to be significant determinants of the risk of thromboembolism. Awareness of the clinical aspects influencing cardioversion safety should be raised.
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Affiliation(s)
- Samuli Jaakkola
- a Heart Center , Turku University Hospital and University of Turku , Turku , Finland
| | - Tuomas O Kiviniemi
- a Heart Center , Turku University Hospital and University of Turku , Turku , Finland
| | - K E Juhani Airaksinen
- a Heart Center , Turku University Hospital and University of Turku , Turku , Finland
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Lip GY, Banerjee A, Boriani G, Chiang CE, Fargo R, Freedman B, Lane DA, Ruff CT, Turakhia M, Werring D, Patel S, Moores L. Antithrombotic Therapy for Atrial Fibrillation. Chest 2018; 154:1121-1201. [DOI: 10.1016/j.chest.2018.07.040] [Citation(s) in RCA: 481] [Impact Index Per Article: 80.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 07/11/2018] [Accepted: 07/24/2018] [Indexed: 02/08/2023] Open
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Vandermolen JL, Sadaf MI, Gehi AK. Management and Disposition of Atrial Fibrillation in the Emergency Department: A Systematic Review. J Atr Fibrillation 2018; 11:1810. [PMID: 30455832 DOI: 10.4022/jafib.1810] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 03/19/2018] [Accepted: 05/26/2018] [Indexed: 12/18/2022]
Abstract
Introduction Management of atrial fibrillation (AF) and atrial flutter (AFL) in the emergency department (ED) varies greatly, and there are currently no United States guidelines to guide management with regard to patient disposition after ED treatment. The aim of this systematic review was to evaluate the literature for decision aids to guide disposition of patients with AF/AFLin the ED, and assess potential outcomes associated with different management strategies in the ED. Methods and Results A systematic review was done using PubMed (MEDLINE), Cochrane Central Register of Controlled Trials (CENTRAL), and EMBASE, combining the search terms "Atrial Fibrillation", "Atrial Flutter", "Emergency Medicine", "Emergency Service", and "Emergency Treatment". After removal of duplicates, 754 articles were identified. After initial screening of titles and abstracts, 69full text articles were carefully reviewed and 34 articles were ultimately included in the study based on inclusion and exclusion criteria. The articles were grouped into four main categories: decision aids and outcome predictors, electrical cardioversion-based protocols, antiarrhythmic-based protocols, and general management protocols. Conclusion This systematic review is the first study to our knowledge to evaluate the optimal management of symptomatic AF/AFLin the ED with a direct impact on ED disposition. There are several viable management strategies that can result in safe discharge from the ED in the right patient population, and decision aids can be utilized to guide selection of appropriate patients for discharge.
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Affiliation(s)
- Justin L Vandermolen
- Division of Cardiology, Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Murrium I Sadaf
- Division of Cardiology, Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Anil K Gehi
- Division of Cardiology, Department of Medicine, University of North Carolina, Chapel Hill, NC
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Smith TA. It May Come as No Shock: Cardioversion of Atrial Fibrillation/Atrial Flutter With Ibutilide. Ann Emerg Med 2018; 71:788-792. [DOI: 10.1016/j.annemergmed.2018.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tampieri A, Cipriano V, Mucci F, Rusconi AM, Lenzi T, Cenni P. Safety of cardioversion in atrial fibrillation lasting less than 48 h without post-procedural anticoagulation in patients at low cardioembolic risk. Intern Emerg Med 2018; 13:87-93. [PMID: 28025766 DOI: 10.1007/s11739-016-1589-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 12/01/2016] [Indexed: 10/20/2022]
Abstract
Currently, there is no unified consensus on short-term anticoagulation after cardioversion of atrial fibrillation lasting less than 48 h in low-cardioembolic-risk patients. The aim of this study is to evaluate the rate of transient ischemic attacks, stroke and death in this subset of patients after cardioversion without post-procedural anticoagulation. In a prospective observational study, patients with recent-onset AF undergoing cardioversion attempts in the Emergency Department were evaluated over the past 3 years. Inclusion criteria were conversion to sinus rhythm, low thromboembolic risk defined by a CHA2DS2VASc score of 0-1 points for males (0-2 points for females aged over 65 years), and hospital discharge without anticoagulant treatment. Patients with severe valvular heart disease, underlying systemic causes of AF, and those discharged with anticoagulant therapy were excluded. The main outcomes measured were TIA, stroke and death at thirty days' follow-up after discharge. During the study period, 218 successful cardioversions, obtained both electrically and pharmacologically, were performed on 157 patients. One hundred and eleven patients were males (71%), the mean age was 55.2 years (±standard deviation 10.7), 99 patients (63%) reported a CHA2DS2VASc score of 0, and the remaining 58 (37%) had a risk profile of 1 point. Of these, latter 8 were females (5%) older than 65 years (risk score 2 points). At the thirty days outcome, none of the 150 enrolled patients who completed a follow-up visit has reported TIA or stroke, nor died, in the overall 211 successful cardioversions evaluated. In our study, the rate of thromboembolic events after cardioversion of recent-onset AF of less than 48 h duration, in patients with a 0-1 CHA2DS2VASc risk profile (females 0-2), appeared to be extremely low even in absence of post-procedural anticoagulation. These findings seem to confirm data from previous studies, and suggest that routine post-procedural short-term anticoagulation may be considered as an overtreatment in this very low-risk subset of patients.
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Affiliation(s)
- Andrea Tampieri
- Emergency Department, S.Maria della Scaletta Hospital, via Montericco 4, Imola, 40026, Bologna, Italy.
| | - Valentina Cipriano
- Emergency Department, S.Maria della Scaletta Hospital, via Montericco 4, Imola, 40026, Bologna, Italy
| | - Fabrizio Mucci
- Emergency Department, S.Maria della Scaletta Hospital, via Montericco 4, Imola, 40026, Bologna, Italy
| | | | - Tiziano Lenzi
- Emergency Department, S.Maria della Scaletta Hospital, via Montericco 4, Imola, 40026, Bologna, Italy
| | - Patrizia Cenni
- Emergency Department, S.Maria della Scaletta Hospital, via Montericco 4, Imola, 40026, Bologna, Italy
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Abstract
The prevalence of atrial fibrillation is increasing rapidly, resulting in more patients presenting for care in the emergency department and in-hospital settings. To reduce morbidity and mortality, and improve patient quality of life, clinicians working in these settings need to be both current and facile in their approach to management of these patients. Frequent updates to guideline recommendations (based on emerging research) make this challenging for practicing physicians. This article reviews the acute management of atrial fibrillation in the emergency and in-hospital settings, including practical approaches to rhythm and rate control, anticoagulation, and special situations, incorporating the most up-to-date guidelines.
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Affiliation(s)
- Clare L Atzema
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre, Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, G146, Toronto, ON M4N 3M5, Canada.
| | - Sheldon M Singh
- Division of Cardiology, Department of Medicine, University of Toronto, Schulich Heart Program, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, A222, Toronto, ON M4N 3M5, Canada
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Rankin AJ, Rankin SH. Cardioverting acute atrial fibrillation and the risk of thromboembolism: not all patients are created equal . Clin Med (Lond) 2017; 17:419-423. [PMID: 28974590 PMCID: PMC6301939 DOI: 10.7861/clinmedicine.17-5-419] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Current guidelines support the well-established clinical practice that patients who present with atrial fibrillation (AF) of less than 48 hours duration should be considered for cardioversion, even in the absence of pre-existing anticoagulation. However, with increasing evidence that short runs of AF confer significant risk of stroke, on what evidence is this 48-hour rule based and is it time to adopt a new approach? We review existing evidence and suggest a novel approach to risk stratification in this setting. Overall, the risk of thromboembolism associated with acute cardioversion of patients with AF that is estimated to be of <48 hours duration is low. However, this risk varies widely depending on patient characteristics. From existing evidence, we show that using the CHA2DS2-VASc score may allow better selection of appropriate patients in order to prevent exposing specific patient groups to an unacceptably high risk of a potentially devastating complication.
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Affiliation(s)
- Alastair J Rankin
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
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Butler M, Froese P, Zed P, Kovacs G, MacKinley R, Magee K, Watson ML, Campbell SG. Emergency department procedural sedation for primary electrical cardioversion - a comparison with procedural sedations for other reasons. World J Emerg Med 2017; 8:165-169. [PMID: 28680511 DOI: 10.5847/wjem.j.1920-8642.2017.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common arrhythmia treated in the emergency department (ED), with primary electrical cardioversion (PEC) the preferred method of rhythm control. Anecdotally, patients undergoing ED procedural sedation (EDPS) for PEC differ from those requiring EDPS for other procedures: they are at higher risk of adverse events, and require fewer drugs and lower doses. We attempt to verify this using an EDPS registry at a Canadian, tertiary care teaching hospital. METHODS This is a retrospective review of patients that underwent EDPS for the period of June 2006 to September 2014. We compared demographics, medication use and intra-procedural adverse events between those receiving EDPS for PEC for AF compared to that for other indications. We report the asssociation between AEs and predictors using logistic regression. RESULTS A total of 4 867 patients were included, 714 for PEC for AF and 4 153 for other indications. PEC patients were more likely male (58.5% vs. 47.1%), older (59.5 years vs. 48.1 years), and less likely to be ASA I (46.6% vs. 69.0%). PEC patients received smaller doses of propofol and less likely to receive adjuvant analgesic therapy (11.5% vs. 78.2%). PEC patients were more likely to experience hypotension (27.6% vs. 16.5%) but respiratory AEs (apnea, hypoxia and airway intervention) were not different. CONCLUSION EDPS for PEC differs from that conducted for other purposes: patients tend to be less healthy, receive smaller doses of medication and more likely to suffer hypotension without an increase in respiratory AEs. These factors should be considered when performing EDPS.
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Affiliation(s)
- Michael Butler
- Department of Emergency Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia B3H 3A6, Canada.,Department of Undergraduate Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia B3H 3A6, Canada
| | - Patrick Froese
- Department of Emergency Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia B3H 3A6, Canada
| | - Peter Zed
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia V6T 1Z3, Canada.,Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia V6T 1Z3, Canada
| | - George Kovacs
- Department of Emergency Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia B3H 3A6, Canada
| | - Robert MacKinley
- Department of Emergency Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia B3H 3A6, Canada
| | - Kirk Magee
- Department of Emergency Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia B3H 3A6, Canada
| | - Mary-Lynn Watson
- Department of Emergency Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia B3H 3A6, Canada
| | - Samuel G Campbell
- Department of Emergency Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia B3H 3A6, Canada
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Outcomes for Emergency Department Patients With Recent-Onset Atrial Fibrillation and Flutter Treated in Canadian Hospitals. Ann Emerg Med 2017; 69:562-571.e2. [DOI: 10.1016/j.annemergmed.2016.10.013] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 10/05/2016] [Accepted: 10/12/2016] [Indexed: 11/22/2022]
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Jaakkola S, Lip GY, Biancari F, Nuotio I, Hartikainen JE, Ylitalo A, Airaksinen KJ. Predicting Unsuccessful Electrical Cardioversion for Acute Atrial Fibrillation (from the AF-CVS Score). Am J Cardiol 2017; 119:749-752. [PMID: 28017305 DOI: 10.1016/j.amjcard.2016.11.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 11/08/2016] [Accepted: 11/08/2016] [Indexed: 11/25/2022]
Abstract
Electrical cardioversion (ECV) is the standard treatment for acute atrial fibrillation (AF), but identification of patients with increased risk of ECV failure or early AF recurrence is of importance for rational clinical decision-making. The objective of this study was to derive and validate a clinical risk stratification tool for identifying patients at high risk for unsuccessful outcome after ECV for acute AF. Data on 2,868 patients undergoing 5,713 ECVs of acute AF in 3 Finnish hospitals from 2003 through 2010 (the FinCV study data) were included in the analysis. Patients from western (n = 3,716 cardioversions) and eastern (n = 1,997 cardioversions) hospital regions were used as derivation and validation datasets. The composite of cardioversion failure and recurrence of AF within 30 days after ECV was recorded. A clinical scoring system was created using logistic regression analyses with a repeated-measures model in the derivation data set. A multivariate analysis for prediction of the composite end point resulted in identification of 5 clinical variables for increased risk: Age (odds ratio [OR] 1.31, confidence interval [CI] 1.13 to 1.52), not the First AF (OR 1.55, CI 1.19 to 2.02), Cardiac failure (OR 1.52, CI 1.08 to 2.13), Vascular disease (OR 1.38, CI 1.11 to 1.71), and Short interval from previous AF episode (within 1 month before ECV, OR 2.31, CI 1.83 to 2.91) [hence, the acronym, AF-CVS]. The c-index for the AF-CVS score was 0.67 (95% CI 0.65 to 0.69) with Hosmer-Lemeshow p value 0.84. With high (>5) scores (i.e., 12% to 16% of the patients), the rate of composite end point was ∼40% in both cohorts, and among low-risk patients (score <3), the composite end point rate was ∼10%. In conclusion, the risk of ECV failure and early recurrence of AF can be predicted with simple patient and disease characteristics.
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RAMIREZ FDANIEL, FISET SANDRAL, CLELAND MARKJ, ZAKUTNEY TIMOTHYJ, NERY PABLOB, NAIR GIRISHM, REDPATH CALUMJ, SADEK MOUHANNADM, BIRNIE DAVIDH. Effect of Applying Force to Self-Adhesive Electrodes on Transthoracic Impedance: Implications for Electrical Cardioversion. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2016; 39:1141-1147. [DOI: 10.1111/pace.12937] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 07/20/2016] [Accepted: 08/18/2016] [Indexed: 11/28/2022]
Affiliation(s)
- F. DANIEL RAMIREZ
- Arrhythmia Service; University of Ottawa Heart Institute; Ottawa Ontario Canada
| | - SANDRA L. FISET
- Biomedical Engineering; University of Ottawa Heart Institute; Ottawa Ontario Canada
| | - MARK J. CLELAND
- Biomedical Engineering; University of Ottawa Heart Institute; Ottawa Ontario Canada
| | - TIMOTHY J. ZAKUTNEY
- Biomedical Engineering; University of Ottawa Heart Institute; Ottawa Ontario Canada
| | - PABLO B. NERY
- Arrhythmia Service; University of Ottawa Heart Institute; Ottawa Ontario Canada
| | - GIRISH M. NAIR
- Arrhythmia Service; University of Ottawa Heart Institute; Ottawa Ontario Canada
| | - CALUM J. REDPATH
- Arrhythmia Service; University of Ottawa Heart Institute; Ottawa Ontario Canada
| | - MOUHANNAD M. SADEK
- Arrhythmia Service; University of Ottawa Heart Institute; Ottawa Ontario Canada
| | - DAVID H. BIRNIE
- Arrhythmia Service; University of Ottawa Heart Institute; Ottawa Ontario Canada
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Katritsis DG, Josephson ME. Anticoagulation for Cardioversion of Acute Onset Atrial Fibrillation. JACC Clin Electrophysiol 2016; 2:495-497. [DOI: 10.1016/j.jacep.2016.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 03/10/2016] [Indexed: 11/29/2022]
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Garg A, Khunger M, Seicean S, Chung MK, Tchou PJ. Incidence of Thromboembolic Complications Within 30 Days of Electrical Cardioversion Performed Within 48 Hours of Atrial Fibrillation Onset. JACC Clin Electrophysiol 2016; 2:487-494. [PMID: 29759870 DOI: 10.1016/j.jacep.2016.01.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 12/28/2015] [Accepted: 01/28/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVES This study sought to compare the risk of thromboembolism after cardioversion within 48 h of atrial fibrillation (AF) onset in patients therapeutically versus not therapeutically anticoagulated. BACKGROUND Although guidelines do not mandate anticoagulation for cardioversion within 48 h of AF onset, risk of thromboembolism in this group has been understudied. METHODS Patients undergoing cardioversion within 48 h after AF onset were identified from a prospectively collected database and retrospectively reviewed to determine anticoagulation status and major thromboembolic events within 30 days of cardioversion. RESULTS Among 567 cardioversions in 484 patients without therapeutic anticoagulation (mean CHA2DS2-VASc score, 2.3 ± 1.7), 6 had neurological events (1.06%), all in patients on aspirin alone. Among 898 cardioversions in 709 patients on therapeutic anticoagulation (mean CHA2DS2-VASc score, 2.6 ± 1.7; p = 0.017), 2 neurological events occurred (0.22%; OR: 4.8; p = 0.03), both off anticoagulation at the time of stroke. No thromboembolic events occurred in patients with CHA2DS2-VASc score <2 (p = 0.06) or in patients with postoperative AF. CONCLUSIONS In patients with acute-onset AF, odds of thromboembolic complications were almost 5 times higher in patients without therapeutic anticoagulation at the time of cardioversion. However, no events occurred in post-operative patients and in those with CHA2DS2-VASc scores of <2, supporting the utility of accurate assessment of AF onset and risk stratification in determining the need for anticoagulation for cardioversion of AF <48 h in duration.
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Affiliation(s)
- Aatish Garg
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Monica Khunger
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sinziana Seicean
- Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mina K Chung
- Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Patrick J Tchou
- Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA.
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Jaakkola J, Hartikainen JEK, Kiviniemi T, Nuotio I, Nammas W, Grönberg T, Karmi A, Ylitalo A, Airaksinen KEJ. Ventricular rate during acute atrial fibrillation and outcome of electrical cardioversion: The FinCV Study. Ann Med 2015; 47:341-5. [PMID: 25943162 DOI: 10.3109/07853890.2015.1031821] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The impact of ventricular rate (VR) on the outcome of electrical cardioversion (ECV) of acute atrial fibrillation (AF) is currently unknown. We aimed to determine the effect of VR during acute AF on the success of ECV, recurrence of AF, and occurrence of post-cardioversion complications in 30 days of follow-up. METHODS A total of 6,624 ECVs were performed in 2,821 consecutive patients with AF lasting < 48 hours. VR ≤ 60 bpm was defined low, and VR ≥ 160 bpm high. RESULTS The median VR before ECV was 109 bpm. The success rate of ECV was 94.2%. Bradycardia occurred in 62 (0.9%) and thromboembolic complications in 39 (0.6%) ECVs. Low VR was observed before 75 (1.1%) ECVs, and male sex was its only independent predictor. High VR was observed in 165 (2.5%) ECVs. The independent predictors of high VR were younger age, < 12 h episode duration, no previous history of AF, and alcohol abuse. Low or high VR were not related to the success of ECV, incidence of thromboembolic or bradycardic complications, or recurrence of AF, although VR was significantly (P < 0.001) lower in the patients in whom AF recurred. CONCLUSION VR during acute AF does not affect the efficacy or safety of ECV.
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Affiliation(s)
- Jussi Jaakkola
- Heart Center, Turku University Hospital and University of Turku , Finland
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Association of the Ottawa Aggressive Protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter. CAN J EMERG MED 2015; 12:181-91. [DOI: 10.1017/s1481803500012227] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ABSTRACTObjective:There is no consensus on the optimal management of recent-onset episodes of atrial fibrillation or flutter. The approach to these conditions is particularly relevant in the current era of emergency department (ED) overcrowding. We sought to examine the effectiveness and safety of the Ottawa Aggressive Protocol to perform rapid cardioversion and discharge patients with these arrhythmias.Methods:This cohort study enrolled consecutive patient visits to an adult university hospital ED for recent-onset atrial fibrillation or flutter managed with the Ottawa Aggressive Protocol. The protocol includes intravenous chemical cardioversion, electrical cardioversion if necessary and discharge home from the ED.Results:A total of 660 patient visits were included, 95.2% involving atrial fibrillation and 4.9% involving atrial flutter. The mean age of patients enrolled was 64.5 years. In total, 96.8% were discharged home and, of those, 93.3% were in sinus rhythm. All patients were initially administered intravenous procaïnamide, with a 58.3% conversion rate. A total of 243 patients underwent subsequent electrical cardioversion with a 91.7% success rate. Adverse events occurred in 7.6% of cases: hypotension 6.7%, bradycardia 0.3% and 7-day relapse 8.6%. There were no cases of torsades de pointes, stroke or death. The median lengths of stay in the ED were as follows: 4.9 hours overall, 3.9 hours for those undergoing conversion with procaïnamide and 6.5 hours for those requiring electrical conversion.Conclusion:This is the largest study to date to evaluate the Ottawa Aggressive Protocol, a unique approach to cardioversion for ED patients with recent-onset episodes of atrial fibrillation and flutter. Our data demonstrate that the Ottawa Aggressive Protocol is effective, safe and rapid, and has the potential to significantly reduce hospital admissions and expedite ED care.
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Scheuermeyer FX, Pourvali R, Rowe BH, Grafstein E, Heslop C, MacPhee J, McGrath L, Ward J, Heilbron B, Christenson J. Emergency Department Patients With Atrial Fibrillation or Flutter and an Acute Underlying Medical Illness May Not Benefit From Attempts to Control Rate or Rhythm. Ann Emerg Med 2015; 65:511-522.e2. [DOI: 10.1016/j.annemergmed.2014.09.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 08/27/2014] [Accepted: 09/15/2014] [Indexed: 11/25/2022]
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Stiell IG, Healey JS, Cairns JA. Safety of Urgent Cardioversion for Patients With Recent-Onset Atrial Fibrillation and Flutter. Can J Cardiol 2015; 31:239-41. [DOI: 10.1016/j.cjca.2014.11.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 11/26/2014] [Accepted: 11/26/2014] [Indexed: 11/28/2022] Open
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GRÖNBERG TONI, HARTIKAINEN JUHAEK, NUOTIO ILPO, BIANCARI FAUSTO, VASANKARI TUIJA, NIKKINEN MARKO, YLITALO ANTTI, AIRAKSINEN KEJUHANI. Can We Predict the Failure of Electrical Cardioversion of Acute Atrial Fibrillation? The FinCV Study. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2014; 38:368-75. [DOI: 10.1111/pace.12561] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 09/21/2014] [Accepted: 10/29/2014] [Indexed: 11/30/2022]
Affiliation(s)
- TONI GRÖNBERG
- Heart Center; Turku University Hospital and University of Turku; Turku Finland
| | | | - ILPO NUOTIO
- Division of Medicine; Department of Acute Internal Medicine; Turku University Hospital; Turku Finland
| | - FAUSTO BIANCARI
- Department of Surgery; Oulu University Hospital; Oulu Finland
| | - TUIJA VASANKARI
- Heart Center; Turku University Hospital and University of Turku; Turku Finland
| | - MARKO NIKKINEN
- Heart Center; Kuopio University Hospital; Kuopio Finland
| | - ANTTI YLITALO
- Heart Center; Satakunta Central Hospital; Pori Finland
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Verma A, Cairns JA, Mitchell LB, Macle L, Stiell IG, Gladstone D, McMurtry MS, Connolly S, Cox JL, Dorian P, Ivers N, Leblanc K, Nattel S, Healey JS. 2014 focused update of the Canadian Cardiovascular Society Guidelines for the management of atrial fibrillation. Can J Cardiol 2014; 30:1114-30. [PMID: 25262857 DOI: 10.1016/j.cjca.2014.08.001] [Citation(s) in RCA: 320] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 08/02/2014] [Accepted: 08/03/2014] [Indexed: 12/29/2022] Open
Abstract
Atrial fibrillation (AF) is an extremely common clinical problem with an important population morbidity and mortality burden. The management of AF is complex and fraught with many uncertain and contentious issues, which are being addressed by extensive ongoing basic and clinical research. The Canadian Cardiovascular Society AF Guidelines Committee produced an extensive set of evidence-based AF management guidelines in 2010 and updated them in the areas of anticoagulation and rate/rhythm control in 2012. In late 2013, the committee judged that sufficient new information regarding AF management had become available since 2012 to warrant an update to the Canadian Cardiovascular Society AF Guidelines. After extensive evaluation of the new evidence, the committee has updated the guidelines for: (1) stroke prevention principles; (2) anticoagulation of AF patients with chronic kidney disease; (3) detection of AF in patients with stroke; (4) investigation and management of subclinical AF; (5) left atrial appendage closure in stroke prevention; (6) emergency department management of AF; (7) periprocedural anticoagulation management; and (8) rate and rhythm control including catheter ablation. This report presents the details of the updated recommendations, along with their background and rationale. In addition, a complete set of presently applicable recommendations, those that have been updated and those that remain in force from previous guideline versions, is provided in the Supplementary Material.
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Affiliation(s)
- Atul Verma
- Southlake Regional Health Centre, University of Toronto, Newmarket, Ontario, Canada.
| | - John A Cairns
- GLD Health Care Centre, University of British Columbia, Vancouver, British Columbia, Canada
| | - L Brent Mitchell
- Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | - Laurent Macle
- Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Ian G Stiell
- Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - David Gladstone
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | | | - Stuart Connolly
- Hamilton General Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Jafna L Cox
- QEII Health Sciences Centre, Dalhousie University, Hailfax, Nova Scotia, Canada
| | - Paul Dorian
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Noah Ivers
- Women's College Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kori Leblanc
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Stanley Nattel
- Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Jeff S Healey
- Hamilton General Hospital, McMaster University, Hamilton, Ontario, Canada
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Elmouchi DA, VanOosterhout S, Muthusamy P, Khan M, Puetz C, Davis AT, Brown MD. Impact of an emergency department-initiated clinical protocol for the evaluation and treatment of atrial fibrillation. Crit Pathw Cardiol 2014; 13:43-48. [PMID: 24827879 DOI: 10.1097/hpc.0000000000000008] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE Published data supporting the best practice for patients with atrial fibrillation (AF) presenting to the emergency department (ED) are limited. Our objective was to evaluate the impact of an AF clinical protocol initiated in the ED with early follow-up in a specialty AF outpatient clinic. METHODS This was a single-center prospective study of all consented patients with AF who were discharged from the ED through the AF clinical pathway and were then seen in the AF clinic. The primary endpoint was the rate of 90-day hospitalization/ED visits. Secondary endpoints included adherence to established AF anticoagulation guidelines, rate of thromboembolic events, quality of life, and patient satisfaction. RESULTS One hundred consecutive patients were enrolled in the study. Within 90 days, 15 had ED visits and 4 were hospitalized, whereas none developed thromboembolic complications. There were significant increases in the Atrial Fibrillation Effect on QualiTy of life survey quality of life (67.3 ± 24.8 vs. 89.2 ± 15.7; P < 0.001) and patient satisfaction (66.4 ± 25.3 vs. 77.9 ± 22.8; P < 0.001) scores from baseline to 90 days. Of the 29 patients with CHADS2 score ≥2, 20 (69%) were discharged from the AF clinic with oral anticoagulation. CONCLUSIONS We describe a novel approach to the care of patients with AF presenting to the ED. Usage of the ED-initiated AF clinical pathway with early follow-up in a protocol-driven AF clinic was associated with low readmission rates, no thromboembolic complications at 90 days, improved quality of life, and high patient satisfaction.
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Affiliation(s)
- Darryl A Elmouchi
- From the *Department of Cardiology, Division of Electrophysiology, Frederik Meijer Heart and Vascular Institute, Grand Rapids, MI; †Department of Internal Medicine, Michigan State University College of Human Medicine, East Lansing, MI; ‡Department of Research, Spectrum Health, Grand Rapids, MI; §Internal Medicine Residency Program, Grand Rapids Medical Education Partners/Michigan State University, Grand Rapids, MI; ¶Hospitalist Medicine, Spectrum Health, Grand Rapids, MI, ‖Department of Emergency Medicine, Spectrum Health, Grand Rapids, MI; **Department of Research, Grand Rapids Medical Education Partners, Grand Rapids, MI; ††Department of Surgery, Michigan State University College of Human Medicine, Grand Rapids, MI; and ‡‡Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI
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Thromboembolic Complications After Cardioversion of Acute Atrial Fibrillation. J Am Coll Cardiol 2013; 62:1187-92. [DOI: 10.1016/j.jacc.2013.04.089] [Citation(s) in RCA: 184] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Revised: 03/28/2013] [Accepted: 04/02/2013] [Indexed: 11/22/2022]
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Cohn BG, Keim SM, Yealy DM. Is Emergency Department Cardioversion of Recent-onset Atrial Fibrillation Safe and Effective? J Emerg Med 2013; 45:117-27. [DOI: 10.1016/j.jemermed.2013.01.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Accepted: 01/24/2013] [Indexed: 10/26/2022]
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Types and outcomes of cardioversion in patients admitted to hospital for atrial fibrillation: results of the German RHYTHM-AF Study. Clin Res Cardiol 2013; 102:713-23. [DOI: 10.1007/s00392-013-0586-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Accepted: 05/31/2013] [Indexed: 10/26/2022]
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Grönberg T, Nuotio I, Nikkinen M, Ylitalo A, Vasankari T, Hartikainen JE, Airaksinen KJ. Arrhythmic complications after electrical cardioversion of acute atrial fibrillation: The FinCV study. ACTA ACUST UNITED AC 2013; 15:1432-5. [DOI: 10.1093/europace/eut106] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Vinson DR, Hoehn CL. Sedation-assisted Orthopedic Reduction in Emergency Medicine: The Safety and Success of a One Physician/One Nurse Model. West J Emerg Med 2013; 14:47-54. [PMID: 23447756 PMCID: PMC3582522 DOI: 10.5811/westjem.2012.4.12455] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Revised: 04/09/2012] [Accepted: 04/30/2012] [Indexed: 02/01/2023] Open
Abstract
Introduction Much of the emergency medical research on sedation-assisted orthopedic reductions has been undertaken with two physicians––one dedicated to the sedation and one to the procedure. Clinical practice in community emergency departments (EDs), however, often involves only one physician, who both performs the procedure and simultaneously oversees the crendentialed registered nurse who administers the sedation medication and monitors the patient. Although the dual-physician model is advocated by some, evidence in support of its superiority is lacking. Methods: In this electronic health records review we describe sedation-assisted closed reductions of major joints and forearm fractures in three suburban community EDs. The type of procedure and sedation medication, need for specialty assistance, success rates, and intervention-requiring adverse events are reported. Results: During the 18-month study period, procedural sedation was performed 457 times on 442 patients undergoing closed reduction for shoulder dislocations (n = 111), elbow dislocations (n = 29), hip dislocations (n = 101), and forearm fractures (n = 201). In the vast majority of this cohort (98.4% [435/442]), a single emergency physician simultaneously managed both the procedural sedation and the initial orthopedic reduction without the assistance of a second physician. The reduction was successful or satisfactory in 96.6% (425/435; 95% confidence interval [CI], 95.8–98.8%) of these cases, with a low incidence of intervention-requiring adverse events (2.8% [12/435]; 95% CI, 1.5–4.8%). Conclusion: Sedation-assisted closed reduction of major joint dislocations and forearm fractures can be performed effectively and safely in the ED using a one physician/one nurse model. A policy that requires a separate physician (or nurse anesthetist) to administer medications for all sedation-assisted ED procedures appears unwarranted. Further research is needed to determine which specific clinical scenarios might benefit from a dual-physician approach.
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Affiliation(s)
- David R Vinson
- Kaiser Permanente Roseville Medical Center, Department of Emergency Medicine, Roseville, California ; The Permanente Medical Group, Oakland, California
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47
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Scheuermeyer FX, Grafstein E, Stenstrom R, Innes G, Heslop C, MacPhee J, Pourvali R, Heilbron B, McGrath L, Christenson J. Thirty-Day and 1-Year Outcomes of Emergency Department Patients With Atrial Fibrillation and No Acute Underlying Medical Cause. Ann Emerg Med 2012; 60:755-765.e2. [DOI: 10.1016/j.annemergmed.2012.05.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Revised: 05/02/2012] [Accepted: 05/08/2012] [Indexed: 10/28/2022]
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Rogenstein C, Kelly AM, Mason S, Schneider S, Lang E, Clement CM, Stiell IG. An international view of how recent-onset atrial fibrillation is treated in the emergency department. Acad Emerg Med 2012; 19:1255-60. [PMID: 23167856 DOI: 10.1111/acem.12016] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Revised: 06/21/2012] [Accepted: 07/12/2012] [Indexed: 12/01/2022]
Abstract
OBJECTIVES This study was conducted to determine if there is practice variation for emergency physicians' (EPs) management of recent-onset atrial fibrillation (RAF) in various world regions (Canada, United States, United Kingdom, and Australasia). METHODS The authors completed a mail and e-mail survey of members from four national emergency medicine (EM) associations. One prenotification letter and three survey letters were sent to members of the Canadian Association of Emergency Physicians (CAEP; Canada-1,177 members surveyed), American College of Emergency Physicians (ACEP; United States-500), College of Emergency Medicine UK (CEM; United Kingdom-1,864), and Australasian College for Emergency Medicine (ACEM; Australasia-1,188) as per the modified Dillman technique. The survey contained 23 questions related to the management of adult patients with symptomatic RAF (either a first episode or paroxysmal-recurrent) where onset is less than 48 hours and cardioversion is considered a treatment option. Data were analyzed using descriptive and chi-square statistics. RESULTS Response rates were as follows: overall, 40.5%; Canada, 43.0%; United States, 50.1%; United Kingdom, 38.1%; and Australasia, 38.0%. Physician demographics were as follows: 72% male and mean (±SD) age 41.7 (±8.39) years. The proportions of physicians attempting rate control as their initial strategy are United States, 94.0%; Canada, 70.7%; Australasia, 61.1%; and United Kingdom, 43.1% (p < 0.0001). Diltiazem is the predominant agent for rate control in Canada (65.36%) and the United States (95.22%), while metoprolol is used in Australasia (65.94%) and the United Kingdom (67.64%). Cardioversion is attempted at varying rates in Canada (65.9%), Australasia (49.9%), United Kingdom (49.5%), and the United States (25.9%) (p < 0.0001). Pharmacologic cardioversion is attempted first in all regions, with the preferred drug being procainamide in Canada (61.93%) and amiodarone in Australasia (63.39%), the United Kingdom (47.97%), and the United States (22.41%; p < 0.0001). If drugs fail, electrical cardioversion is then attempted in Canada (70.64%), Australasia (46.19%), the United States (29.69%), and the United Kingdom (27.78%; p < 0.0001). CONCLUSIONS There is much variation in emergency department (ED) management of RAF among world regions, most markedly for use of rate versus rhythm control, choice of drugs, and use of electrical cardioversion. Canadians are more likely to use an aggressive approach for management of RAF, whereas Americans are more likely to employ conservative management. U.K. and Australasian EPs fall somewhere in the middle. These differences demonstrate the need for better evidence, or better synthesis of existing knowledge, to create guidelines to guide ED management of this common dysrhythmia.
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Affiliation(s)
- Carly Rogenstein
- Department of Emergency Medicine; Ottawa Hospital Research Institute; University of Ottawa; Ottawa Ontario Canada
| | - Anne-Maree Kelly
- Joseph Epstein Centre for Emergency Medicine Research at Western Health and the University of Melbourne; Melbourne Victoria Australia
| | - Suzanne Mason
- Department of Emergency and Immediate Care; University of Sheffield; Sheffield United Kingdom
| | - Sandra Schneider
- Department of Emergency Medicine; University of Rochester; Rochester NY
| | - Eddy Lang
- Division of Emergency Medicine; University of Calgary; Calgary Alberta Canada
| | - Catherine M. Clement
- Department of Emergency Medicine; Ottawa Hospital Research Institute; University of Ottawa; Ottawa Ontario Canada
| | - Ian G. Stiell
- Department of Emergency Medicine; Ottawa Hospital Research Institute; University of Ottawa; Ottawa Ontario Canada
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Tampieri A, Rusconi AM, Lenzi T. Cardioversion in atrial fibrillation. Focus on recent-onset atrial fibrillation. Intern Emerg Med 2012; 7 Suppl 3:S241-50. [PMID: 23073864 DOI: 10.1007/s11739-012-0863-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Atrial fibrillation is the most common sustained arrhythmia encountered in clinical practice. Its prevalence is rising due to an increasing elderly population and the improvement in management of life-threatening diseases such as myocardial infarction and heart failure. Over the past few years effective non-pharmacological treatments, new antiarrhythmics drugs, and anticoagulants have been introduced. Regardless of rate-control or rhythm control strategy, adequate stroke prevention still remains a cornerstone in the treatment of this arrhythmia. This review aims to illustrate the main practical issues in the management of atrial fibrillation, focusing on patients with recent-onset and hemodynamically stable atrial fibrillation.
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Affiliation(s)
- Andrea Tampieri
- Emergency Department, Ospedale Civile Santa Maria della Scaletta, via Montericco 4, 40026, Imola (Bo), Italy.
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