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Adler S, Mattice AMS, Eagles D, Yadav K, Hui S, Azward A, Pandey N, Stiell I. How well do ED physician practices align with the CAEP acute atrial fibrillation checklist for stroke prevention and disposition? CAN J EMERG MED 2024; 26:327-332. [PMID: 38530599 DOI: 10.1007/s43678-024-00676-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 02/29/2024] [Indexed: 03/28/2024]
Abstract
OBJECTIVES Acute atrial fibrillation (AF)/flutter (AFL) is a common emergency department (ED) presentation. In 2021, an updated version of CAEP's Acute AF/AFL Best Practices Checklist was published, seeking to guide management. We assessed the alignment with and safety of application of the Checklist, regarding stroke prevention and disposition. METHODS This health records review included adults presenting to two tertiary care academic EDs between January and August 2022 with a diagnosis of acute AF/AFL. Patients were excluded if their initial heart rate was < 100 or if they were hospitalized. Data extracted included: demographics, CHADS-65 score, clinical characteristics, ED treatment and disposition, and outpatient prescriptions and referrals. Our primary outcome was the proportion of patient encounters with one or more identified safety issues. Each case was assessed according to seven predetermined criteria from elements of the CAEP Checklist and either deemed "safe" or to contain one or more safety issues. We used descriptive statistics with 95% confidence intervals. RESULTS 358 patients met inclusion criteria. The mean age was 66.9 years, 59.2% were male and 77.4% patients had at least one of the CHADS-65 criteria. 169 (47.2%) were not already on anticoagulation and 99 (27.6%) were discharged home with a new prescription for anticoagulation. The primary outcome was identified in 6.4% (95% CI 4.3-9.5) of encounters, representing 28 safety issues in 23 individuals. The safety concerns included: failure to prescribe anticoagulation when indicated (n = 6), inappropriate dosing of a direct oral anticoagulant (DOAC) (n = 2), inappropriate prescription of rate or rhythm control medication (n = 9), and failure to recommend appropriately timed follow-up for new rate control medication (n = 11). CONCLUSIONS There was a very high level of ED physician alignment with CAEP's Best Practices Checklist regarding disposition and stroke prevention. There are opportunities to further improve care with respect to recommendation of anticoagulation and reducing inappropriate prescriptions of rate or rhythm medications.
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Affiliation(s)
- Samara Adler
- Department of Emergency Medicine, University of Ottawa and Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, ON, Canada.
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Amanda M S Mattice
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Debra Eagles
- Department of Emergency Medicine, University of Ottawa and Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, ON, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa and Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, ON, Canada
| | - Sean Hui
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Althaf Azward
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Nikesh Pandey
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Ian Stiell
- Department of Emergency Medicine, University of Ottawa and Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, ON, Canada
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Mattice AMS, Adler S, Eagles D, Yadav K, Hui S, Azward A, Pandey N, Stiell IG. Assessment of physician compliance to the CAEP 2021 Atrial Fibrillation Best Practices Checklist for rate and rhythm control in the emergency department. CAN J EMERG MED 2024; 26:333-338. [PMID: 38519830 DOI: 10.1007/s43678-024-00669-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/25/2024] [Indexed: 03/25/2024]
Abstract
OBJECTIVES Acute atrial fibrillation and flutter (AF/AFL) are common arrhythmias treated in the emergency department (ED). The 2021 CAEP Best Practices Checklist provides clear recommendations for management of patients with acute AF/AFL. This study aimed to evaluate physician compliance to Checklist recommendations for risk assessment and ED management of AF/AFL. METHODS This health records review assessed the management of adult patients presenting to two tertiary care EDs for management of acute AF/AFL from January to August, 2022. All ECGs demonstrating AF/AFL with a heart rate greater than 100 were compiled to capture primary and secondary causes. All visits were assessed for rate and rhythm control management, adverse events, return to ED, and safety criteria. Study physicians classified safety criteria from the Checklist into high and moderate concerns. The primary outcome was the proportion of cases with safety concerns and adverse events occurring during management in the ED. Data were analyzed using simple descriptive statistics. RESULTS We included 429 patients with a mean age of 67.7 years and 57.1% male. ED management included rate control (20.4%), electrical (40.1%), and pharmacological (20.1%) cardioversion. Adverse events occurred in 9.5% of cases: 12.5% in rate control, 13.4% in electrical cardioversion, and 6.9% in pharmacologic cardioversion. Overall, 7.9% of cases had management safety concerns. Moderate safety concerns occurred in 4.9% of cases including failure to attain recommended heart rate at time of discharge (3.9%). Severe concerns were identified in 3.0% of cases including failure to cardiovert unstable patients (1.2%). The 30-day return-to-ED rate was 16.5% secondary to AF/AFL. CONCLUSION ED management of AF/AFL was consistent with the CAEP Checklist and was safe overall. Opportunities for optimizing care include attaining recommended targets during rate control, avoidance of calcium channel and beta blockers in patients with systolic dysfunction, and earlier cardioversion for clinically unstable patients.
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Affiliation(s)
- Amanda M S Mattice
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Samara Adler
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Sean Hui
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Althaf Azward
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Nikesh Pandey
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
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3
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Liu S, Stiell I, Eagles D, Borgundvaag B, Grewal K. Hypotension and respiratory events related to electrical cardioversion for atrial fibrillation or atrial flutter in the emergency department. CAN J EMERG MED 2024; 26:103-110. [PMID: 38001329 DOI: 10.1007/s43678-023-00621-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023]
Abstract
INTRODUCTION Electrical cardioversion for atrial fibrillation/atrial flutter (AF/AFL) is common in the ED. Our previous work showed that hypotension and respiratory events were important adverse events that occurred in patients undergoing electrical cardioversion for AF/AFL. The purpose of this study was to examine if (1) beta-blockers or calcium channel blocker use prior to ECV were associated with hypotension and (2) medications used for procedural sedation were associated with respiratory events. METHODS This was a secondary analysis of pooled study data from four previous multicentred studies on AF/AFL. We conducted a multivariable logistic regression to examine predictors of hypotension and respiratory adverse events. RESULTS There were 1736 patients who received ECV. A hypotensive event occurred in 62 (3.6%) patients. There was no significant difference in the odds of a hypotensive event in patients who received a beta-blocker or calcium channel blocker in the ED compared to no rate control. Procedural sedation with fentanyl (OR 2.01 95% CI 1.15-3.51) and home beta-blocker use (OR 1.92, 95% CI 1.14-3.21) were significantly associated with hypotensive events. A respiratory event occurred in 179 (10.3%) patients. Older age (OR 2.02, 95% CI 1.30- 3.15) and receiving midazolam for procedural sedation were found to be significantly associated with respiratory events (OR 1.99, 95% CI 1.02-3.88). CONCLUSION Beta-blocker or calcium channel blocker use prior to ECV for AF/AFL was not associated with hypotension. However, sedation with fentanyl and home beta-blocker use was associated with hypotension. The use of midazolam for procedural sedation was significantly associated with respiratory events.
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Affiliation(s)
- Sharon Liu
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Toronto, ON, Canada
- Division of Emergency Medicine, Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Ian Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Bjug Borgundvaag
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Toronto, ON, Canada
- Division of Emergency Medicine, Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Keerat Grewal
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Toronto, ON, Canada.
- Division of Emergency Medicine, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
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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: 276] [Impact Index Per Article: 276.0] [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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5
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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: 66] [Impact Index Per Article: 66.0] [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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Gehi AK, Armbruster T, Walker J, Rosman L, Laux J, Becker A, Aladesanmi O, Mazzella AJ, Deyo Z, Biese K. Implementation of an Atrial Fibrillation Decision Aid Care Pathway in the Emergency Department Reduces Atrial Fibrillation Hospitalizations. Circ Cardiovasc Qual Outcomes 2023; 16:e009808. [PMID: 37492958 DOI: 10.1161/circoutcomes.122.009808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 06/27/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND A straightforward decision aid to guide disposition of atrial fibrillation (AF) patients in the emergency department (ED) was developed for use by ED providers. The implementation of this decision aid in the ED has not been studied. METHODS A pragmatic stepped-wedge cluster approach for analysis of retrospectively collected electronic health record data was used in which 5 hospitals were selected to commence the intervention at periodic intervals following an initial 1-year baseline assessment with 5 additional hospitals included in the comparison group (all in North Carolina). The primary end point of analysis was hospitalization rate. Hierarchical multivariable logistic regression analyses for admission as a function of the intervention while controlling for prespecified patient and hospital predictors were performed with clustering done at the hospital level. RESULTS Between October 2017 and May 2020, a total of 11 458 patients (mean age, 71.4; 50.5% female) presented to 1 of the 10 hospitals with a primary diagnosis of AF. Absolute admission rate was reduced from 60.5% to 48.3% following the intervention (odds ratio, 0.83 [95% CI, 0.71-0.97]; P=0.016). After adjusting for covariates, the intervention was associated with a small increased rate of return to the ED for AF within 30 days of the initial presentation (1.6% to 2.7%; hazard ratio, 1.70 [95% CI, 1.26-2.31]; P<0.001). CONCLUSIONS We demonstrate that implementation of a novel decision aid to guide disposition of patients primary diagnosis of AF presenting to the ED was associated with a reduced admission rate independent of patient and hospital factors. Use of the protocol was associated with a small but significant increase in rate of repeat presentations for AF at 30-day follow-up. Use of a decision aid such as the one described here represents an important tool to reduce unnecessary AF hospitalizations.
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Affiliation(s)
- Anil K Gehi
- Department of Medicine, Division of Cardiology, University of North Carolina at Chapel Hill (A.G., T.A., J.W., L.R., A.B., O.A., A.J.M.)
| | - Tiffany Armbruster
- Department of Medicine, Division of Cardiology, University of North Carolina at Chapel Hill (A.G., T.A., J.W., L.R., A.B., O.A., A.J.M.)
| | - Jennifer Walker
- Department of Medicine, Division of Cardiology, University of North Carolina at Chapel Hill (A.G., T.A., J.W., L.R., A.B., O.A., A.J.M.)
| | - Lindsey Rosman
- Department of Medicine, Division of Cardiology, University of North Carolina at Chapel Hill (A.G., T.A., J.W., L.R., A.B., O.A., A.J.M.)
| | - Jeffrey Laux
- University of North Carolina at Chapel Hill Gillings School of Global Public Health (J.L.)
| | - Ari Becker
- Department of Medicine, Division of Cardiology, University of North Carolina at Chapel Hill (A.G., T.A., J.W., L.R., A.B., O.A., A.J.M.)
| | - Oludamilola Aladesanmi
- Department of Medicine, Division of Cardiology, University of North Carolina at Chapel Hill (A.G., T.A., J.W., L.R., A.B., O.A., A.J.M.)
| | - Anthony J Mazzella
- Department of Medicine, Division of Cardiology, University of North Carolina at Chapel Hill (A.G., T.A., J.W., L.R., A.B., O.A., A.J.M.)
| | - Zachariah Deyo
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, Chapel Hill, NC (Z.D.)
| | - Kevin Biese
- Department of Emergency Medicine, University of North Carolina at Chapel Hill (K.B.)
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7
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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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8
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Vinson DR, Rauchwerger AS, Karadi CA, Shan J, Warton EM, Zhang JY, Ballard DW, Mark DG, Hofmann ER, Cotton DM, Durant EJ, Lin JS, Sax DR, Poth LS, Gamboa SH, Ghiya MS, Kene MV, Ganapathy A, Whiteley PM, Bouvet SC, Babakhanian L, Kwok EW, Solomon MD, Go AS, Reed ME. Clinical decision support to Optimize Care of patients with Atrial Fibrillation or flutter in the Emergency department: protocol of a stepped-wedge cluster randomized pragmatic trial (O'CAFÉ trial). Trials 2023; 24:246. [PMID: 37004068 PMCID: PMC10064588 DOI: 10.1186/s13063-023-07230-2] [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: 07/11/2022] [Accepted: 03/08/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Management of adults with atrial fibrillation (AF) or atrial flutter in the emergency department (ED) includes rate reduction, cardioversion, and stroke prevention. Different approaches to these components of care may lead to variation in frequency of hospitalization and stroke prevention actions, with significant implications for patient experience, cost of care, and risk of complications. Standardization using evidence-based recommendations could reduce variation in management, preventable hospitalizations, and stroke risk. METHODS We describe the rationale for our ED-based AF treatment recommendations. We also describe the development of an electronic clinical decision support system (CDSS) to deliver these recommendations to emergency physicians at the point of care. We implemented the CDSS at three pilot sites to assess feasibility and solicit user feedback. We will evaluate the impact of the CDSS on hospitalization and stroke prevention actions using a stepped-wedge cluster randomized pragmatic clinical trial across 13 community EDs in Northern California. DISCUSSION We hypothesize that the CDSS intervention will reduce hospitalization of adults with isolated AF or atrial flutter presenting to the ED and increase anticoagulation prescription in eligible patients at the time of ED discharge and within 30 days. If our hypotheses are confirmed, the treatment protocol and CDSS could be recommended to other EDs to improve management of adults with AF or atrial flutter. TRIAL REGISTRATION ClinicalTrials.gov NCT05009225 . Registered on 17 August 2021.
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Affiliation(s)
- David R Vinson
- The Permanente Medical Group, Oakland, CA, USA.
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.
- Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, CA, USA.
| | - Adina S Rauchwerger
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Chandu A Karadi
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Jose Medical Center, San Jose, CA, USA
| | - Judy Shan
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - E Margaret Warton
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Jennifer Y Zhang
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Dustin W Ballard
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Rafael Medical Center, San Rafael, CA, USA
| | - Dustin G Mark
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Erik R Hofmann
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente South Sacramento Medical Center, Sacramento, CA, USA
| | - Dale M Cotton
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente South Sacramento Medical Center, Sacramento, CA, USA
| | - Edward J Durant
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Modesto Medical Center, Modesto, CA, USA
| | - James S Lin
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA, USA
| | - Dana R Sax
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Luke S Poth
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, CA, USA
| | - Stephen H Gamboa
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
| | - Meena S Ghiya
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente South San Francisco Medical Center, San Francisco, CA, USA
| | - Mamata V Kene
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Leandro Medical Center, San Leandro, CA, USA
| | - Anuradha Ganapathy
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Jose Medical Center, San Jose, CA, USA
| | - Patrick M Whiteley
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Jose Medical Center, San Jose, CA, USA
| | - Sean C Bouvet
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, CA, USA
| | | | | | - Matthew D Solomon
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Cardiology, Oakland Medical Center, Oakland, CA, USA
| | - Alan S Go
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Departments of Epidemiology, Biostatistics, and Medicine, University of California, San Francisco, CA, USA
- Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Mary E Reed
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
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9
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Mazzella AJ, Hendrickson MJ, Glorioso TJ, Sherwood D, Essig J, Grunwald G, Rosman L, Gehi AK. Interhospital Variability in Utilization of Cardioversion for Atrial Fibrillation in the Emergency Department. Am J Cardiol 2023; 191:101-109. [PMID: 36669379 DOI: 10.1016/j.amjcard.2022.12.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 10/24/2022] [Accepted: 12/26/2022] [Indexed: 01/19/2023]
Abstract
The role for direct current cardioversion (DCCV) in the management of atrial fibrillation (AF) in the emergency department (ED) is unclear. Factors associated with DCCV in current practice are not well described, nor is the variation across patients and institutions. All ED encounters with a primary diagnosis of AF were identified from the Nationwide Emergency Department Sample from 2006 to 2017. The independent association of patient and hospital factors with use of DCCV was assessed using multivariable hierarchical logistic regression. The relative contributions of patient, hospital, and unmeasured hospital factors were assessed using reference effect measures methods. Among 1,280,914 visits to 3,264 EDs with primary diagnosis of AF, 31,422 patients (2.4%) underwent DCCV in the ED. History of stroke (odds ratio [OR] 0.14, 95% confidence interval [CI] 0.09 to 0.22, p <0.001) and dementia (OR 0.14, 95% CI 0.10 to 0.19, p <0.001) was associated with lowest odds of DCCV. Comparing patients more likely to receive DCCV (ninety-fifth percentile) with patients with median risk, the influence of unmeasured hospital factors (OR 14.13, 95% CI 12.55 to 16.09) exceeded the contributions of patient (OR 5.66, 95% CI 5.28 to 6.15) and measured hospital factors (OR 3.89, 95% CI 2.87 to 5.60). In conclusion, DCCV use in the ED varied widely across institutions. Disproportionately large unmeasured hospital variation suggests that presenting hospital is the most determinative factor in the use of DCCV for ED management of AF. Clarification is needed on best practices for management of AF in the ED, including the use of DCCV.
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Affiliation(s)
- Anthony J Mazzella
- Division of Cardiology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | | | - Thomas J Glorioso
- Veterans Health Administration Office of Quality and Patient Safety, US Department of Veterans Affairs, Washington DC
| | - Dalton Sherwood
- University of North Carolina Hospitals, Chapel Hill, North Carolina
| | - Jeremiah Essig
- University of North Carolina Hospitals, Chapel Hill, North Carolina
| | - Gary Grunwald
- Veterans Health Administration Office of Quality and Patient Safety, US Department of Veterans Affairs, Washington DC; Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Denver, Colorado
| | - Lindsey Rosman
- Division of Cardiology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Anil K Gehi
- Division of Cardiology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
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10
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Atzema CL, Stiell IG, Chong AS, Austin PC. Validating emergency department cardioversion procedures in provincial administrative data in Ontario, Canada. PLoS One 2022; 17:e0277598. [PMID: 36454739 PMCID: PMC9714737 DOI: 10.1371/journal.pone.0277598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 11/01/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Cardioversion of acute-onset atrial fibrillation (AF) via electrical or pharmacological means is a common procedure performed in many emergency departments. While these procedures appear to be very safe, the rarity of subsequent adverse outcomes such as stroke would require huge sample sizes to confirm that conclusion. Big data can supply such sample sizes. OBJECTIVE We aimed to validate several potential codes for successful emergency department cardioversion of AF patients. METHODS This study combined 3 observational datasets of emergency department AF visits seen at one of 26 hospitals in Ontario, Canada, between 2008 and 2012. We linked patients who were eligible for emergency department cardioversion to several province-wide health administrative datasets to search for the associated cardioversion billing and procedural codes. Using the observational data as the gold standard for successful cardioversion, we calculated the test characteristics of a billing code (Z437) and of procedural codes 1.HZ.09JAFS and 1.HZ.09JAJS. Both include pharmacological and electrical cardioversions, as well as unsuccessful attempts; the latter is <10% using electricity (in Canada, standard practice is to proceed to electrical cardioversion if pharmacological cardioversion is unsuccessful). RESULTS Of 4557 unique patients in the three datasets, 2055 (45.1%) were eligible for cardioversion. Nine hundred thirty-three (45.4%) of these were successfully cardioverted to normal sinus rhythm. The billing code had slightly better test characteristics overall than the procedural codes. Positive predictive value (PPV) of a billing was 89.8% (95% CI, 87.0-92.2), negative predictive value (NPV) 70.5% (95% CI, 68.1-72.8), sensitivity 52.1% (95% CI, 48.8-55.3), and specificity 95.1% (95% CI, 93.7-96.3). CONCLUSIONS AF patients who have been successfully cardioverted in an emergency department can be identified with high PPV and specificity using a billing code. Studies that require high sensitivity for cardioversion should consider other methods to identify cardioverted patients.
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Affiliation(s)
- Clare L. Atzema
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Division of Emergency Medicine, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Institute for Health Policy, Management and Evaluation, Toronto, ON, Canada
- * E-mail:
| | - Ian G. Stiell
- University of Toronto, Toronto, ON, Canada
- Ottawa University of Health Sciences, Ottawa, ON, Canada
| | | | - Peter C. Austin
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Institute for Health Policy, Management and Evaluation, Toronto, ON, Canada
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11
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A Novel Orderset Driven Emergency Department Atrial Fibrillation Algorithm to Increase Discharge and Risk-appropriate Anticoagulation. Crit Pathw Cardiol 2022; 21:130-134. [PMID: 35994721 DOI: 10.1097/hpc.0000000000000293] [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
INTRODUCTION Patients with atrial fibrillation (AF) are frequently admitted from the emergency department (ED), and when discharged, are not reliably prescribed indicated anticoagulation. We report the impact of a novel computerized ED AF pathway orderset on discharge rate and risk-appropriate anticoagulation in patients with primary AF. METHODS The orderset included options for rate and rhythm control of primary AF, structured risk assessment for thrombotic complications, recommendations for anticoagulation as appropriate, and follow up with an electrophysiologist. All patients discharged from the ED in whom the AF orderset was utilized over an 18-month period comprised the primary study population. The primary outcome was the rate of appropriate anticoagulation or not according to confirmed CHADS-VASC and HASBLED scores. Additionally, the percentage of primary AF patients discharged directly from the ED was compared in the 18-month periods before and after introduction of the orderset. RESULTS A total of 56 patients, average age 57.8 years and average initial heart rate 126 beats/minute, were included in the primary analysis. All 56 (100%; 95% confidence interval, 94-100) received guideline-concordant anticoagulation. The discharge rates in the pre- and postorderset implementation periods were 29% and 41%, respectively (95% confidence interval for 12% difference, 5-18). CONCLUSIONS Our novel AF pathway orderset was associated with 100% guideline-concordant anticoagulation in patients discharged from the ED. Availability of the orderset was associated with a significant increase in the proportion of ED AF patients discharged.
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12
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Israeli A, Gal D, Younis A, Ehrenberg S, Rozner E, Turgeman Y, Naami E, Naami R, Koren O. Sex-Differences in Atrial Fibrillation Patients: Bias or Proper Management? Vasc Health Risk Manag 2022; 18:347-358. [PMID: 35546968 PMCID: PMC9084509 DOI: 10.2147/vhrm.s366285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 04/30/2022] [Indexed: 11/23/2022] Open
Abstract
Background Studies analyze the degree to which gender-based differences are affected by age and comorbidities show mixed results. Methods Using a retrospective cohort study, we analyzed 327 consecutive patients who presented to the emergency department (ED) due to Atrial Fibrillation (AF) from 2014 to 2017 with follow-up at one year. Results Females with AF were older (p < 0.001), with higher Body Mass Indexes (BMI) (p < 0.001), and a higher rate of hypertension (p < 0.001), hyperlipidemia (p = 0.01), diabetes mellitus (p = 0.05), valvular heart disease (p = 0.05), and thyroid dysfunction (18.3% vs 1.8%, p < 0.001). AF males had higher rate of coronary artery disease (p < 0.001) and heart failure with reduced ejection fraction (p < 0.001). Females were managed with rate control medications more frequently than with antiarrhythmic (p < 0.001). After adjusting gender to age and comorbidities, females continued to have higher rates of heart failure hospitalization (Odds Ratio (OR) 2.73 95% Confidence Interval (CI) 1.04-5.89, P-value <0.001) and recurrent AF (OR 3.86, P-value=0.02). Thyroid dysfunction and the lack of antiarrhythmic treatments significantly increased the risk of AF (OR 5.95 95% CI 3.15-9.73, OR 3.42, respectively, P-value <0.001 for both) regardless of gender. The mortality rate differs only in a sub-group of females ≥75 years of age (OR 1.60, P < 0.001). Conclusion AF males and females differ significantly in baseline characteristics and tend to be treated unnecessarily differently for AF. Heart failure hospitalizations and recurrent AF continued to be associated with female AF patients, even after adjusting gender to age and comorbidities. Thyroid dysfunction and AF treatment may explain the higher rates of recurrent AF in female patients.
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Affiliation(s)
- Asaf Israeli
- Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Danna Gal
- Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Autba Younis
- Internal Medicine E, Emek Medical Center, Afula, Israel
| | - Scott Ehrenberg
- Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Ehud Rozner
- Heart Institute, Emek Medical Center, Afula, Israel
| | - Yoav Turgeman
- Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Heart Institute, Emek Medical Center, Afula, Israel
| | - Edmund Naami
- Department of Medicine, University of Illinois College of Medicine, Chicago, IL, USA
| | - Robert Naami
- Department of Medicine, University Hospitals Cleveland Medical center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Ofir Koren
- Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Heart Institute, Emek Medical Center, Afula, Israel
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13
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Tang Y, Wang Y, Sun X, Shi Y, Liu S, Jiang W, Yuan H, Lu Y, Cai J, Wu J. Effect of Early Pharmacologic Cardioversion vs. Non-early Cardioversion in the Patients With Recent-Onset Atrial Fibrillation Within 4-Week Follow-Up Period: A Systematic Review and Network Meta-Analysis. Front Cardiovasc Med 2022; 9:843939. [PMID: 35479281 PMCID: PMC9036487 DOI: 10.3389/fcvm.2022.843939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 03/14/2022] [Indexed: 12/02/2022] Open
Abstract
Background Whether early pharmacologic cardioversion is necessary for recent-onset atrial fibrillation is still controversial. Current meta-analyses were limited to evaluating the effects within 24 h without sufficient considering longer follow-up outcomes. We aimed to compare the effect of early pharmacologic cardioversion and non-early cardioversion in patients with recent-onset atrial fibrillation within 4-weeks of follow-up. Methods We searched the Cochrane Library, EMBASE, MEDLINE, PubMed, Web of Science, ClinicalTrials.gov, and Clinicaltrialsregister. eu for randomized controlled trials (RCTs) published before November 2021 comparing early pharmacologic cardioversion and non-early cardioversion in recent-onset atrial fibrillation and synthesized data in accordance with PRISMA-Systematic Reviews and Network Meta-Analysis (NMA). Early pharmacological cardioversion referred to immediate cardioversion with antiarrhythmic drugs (i.e., amiodarone, propafenone, flecainide, tedisamil, vernakalant, vanoxerine, and sotalol) upon admission, while non-early cardioversion involved the administration of rate-control or placebo medication without immediate cardioversion. Results 16 RCTs with 2,395 patients were included. Compared to non-early cardioversion, a systematic review showed that early pharmacologic cardioversion resulted in a higher probability of sinus rhythm maintenance within 24 h (odds ratios [OR] 2.50, 95% credible interval [CrI] 1.76 to 3.54) and 1-week (2.50, 1.76 to 3.54), however, there was no significant difference in sinus rhythm maintenance within 4-weeks (1.37, 0.90 to 2.09). In subgroup analysis, the Bayesian NMA revealed that vernakalant may be successful in sinus rhythm maintenance within both 24 h (3.55, 2.28 to 5.55) and 1-week (2.72, 1.72 to 4.31). The results were consistent with the frequentist NMA. Conclusions Non-early pharmacologic cardioversion may not be inferior to early cardioversion within a 4-week follow-up period in patients with recent-onset atrial fibrillation. The evidence remains insufficient to determine which antiarrhythmic agent is optimal in the longer run. Further high-quality relevant RCTs are necessary. Clinical Trial Registration PROSPERO CRD42020166862.
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Affiliation(s)
- Yan Tang
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Yujie Wang
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Xuejing Sun
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Yunmin Shi
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Suzhen Liu
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Weihong Jiang
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Hong Yuan
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, China
- Center of Clinical Pharmacology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Yao Lu
- Center of Clinical Pharmacology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Jingjing Cai
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Jingjing Cai
| | - Junru Wu
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, China
- Junru Wu
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14
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Diamant MJ, Andrade JG, Virani SA, Jhund PS, Petrie MC, Hawkins NM. Heart failure and atrial flutter: a systematic review of current knowledge and practices. ESC Heart Fail 2021; 8:4484-4496. [PMID: 34505352 PMCID: PMC8712920 DOI: 10.1002/ehf2.13526] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 06/04/2021] [Accepted: 07/05/2021] [Indexed: 01/14/2023] Open
Abstract
While the interplay between heart failure (HF) and atrial fibrillation (AF) has been extensively studied, little is known regarding HF and atrial flutter (AFL), which may be managed differently. We reviewed the incidence, prevalence, and predictors of HF in AFL and vice versa, and the outcomes of treatment of AFL in HF. A systematic literature review of PubMed/Medline and EMBASE yielded 65 studies for inclusion and qualitative synthesis. No study described the incidence or prevalence of AFL in unselected patients with HF. Most cohorts enrolled patients with AF/AFL as interchangeable diagnoses, or highly selected patients with tachycardia‐induced cardiomyopathy. The prevalence of HF in AFL ranged from 6% to 56%. However, the phenotype of HF was never defined by left ventricular ejection fraction (LVEF). No studies reported the predictors, phenotype, and prognostic implications of AFL in HF. There was significant variation in treatments studied, including the proportion that underwent ablation. When systolic dysfunction was tachycardia‐mediated, catheter ablation demonstrated LVEF normalization in up to 88%, as well as reduced cardiovascular mortality. In summary, AFL and HF often coexist but are understudied, with no randomized trial data to inform care. Further research is warranted to define the epidemiology and establish optimal management.
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Affiliation(s)
- Michael J Diamant
- Division of Cardiology, Royal Columbian Hospital, New Westminster, British Columbia, Canada.,Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason G Andrade
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sean A Virani
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Mark C Petrie
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Nathaniel M Hawkins
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
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15
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Stiell IG, Eagles D, Nemnom MJ, Brown E, Taljaard M, Archambault PM, Birnie D, Borgundvaag B, Clark G, Davis P, Godin D, Hohl C, Mathieu B, McRae AD, Mercier E, Morris J, Parkash R, Perry JJ, Rowe BH, Thiruganasambandamoorthy V, Scheuermeyer F, Sivilotti MLA, Vadeboncoeur A. Adverse Events Associated With Electrical Cardioversion in Patients With Acute Atrial Fibrillation and Atrial Flutter. Can J Cardiol 2021; 37:1775-1782. [PMID: 34474123 DOI: 10.1016/j.cjca.2021.08.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/24/2021] [Accepted: 08/26/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND We sought to evaluate safety of electrical cardioversion (ECV) for patients with acute atrial fibrillation (AF) or atrial flutter (AFL) in the emergency department (ED). METHODS This was an analysis of data from 4 multicentre AF/AFL studies conducted from 2008 to 2019 at 23 large EDs. We included adult patients who received attempts at ECV and who had presented acutely after symptom onset. Staff manually reviewed study and clinical records to abstract data. RESULTS We evaluated 1736 ECV cases with a mean age of 60.1 years and 67.1% male. The overall success of ECV was 90.2% (95% confidence interval 88.7%-91.6%), with 4.9% of patients admitted. ED physicians performed the ECV in 95.2% and provided sedation in 96.5%; 13.9% (12.3%-15.7%) of cases experienced important adverse events that required treatment, and 0.4% were classified as life threatening. Another 5.6% had adverse events that did not require treatment. Logistic regression found that the RAFF-3 study cohort (odds ratio [OR] 2.0), age ≥ 85 years (OR 2.1), coronary artery disease (OR 1.5), midazolam (OR 1.9), and fentanyl (OR 1.5) were associated with important adverse events. CONCLUSIONS This large evaluation of the safety of ECV for acute AF/AFL in the ED found that while serious adverse events were rare, there were a concerning number of events following sedation that required intervention. Physicians should be aware that older age, coronary artery disease, and fentanyl are associated with higher risks of important adverse events. This study provides more information for shared decision making discussions with patients when choosing between drug-shock and shock-only cardioversion strategies.
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Affiliation(s)
- Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Marie-Joe Nemnom
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Erica Brown
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Patrick M Archambault
- Département de Médecine Familiale et de Médicine d'Urgence, Centre de Recherche du Centre Intégré de Santé et de Services Sociaux de Chaudière-Appalaches, Université Laval, Québec City, Québec, Canada; Département d'Anesthésiologie et de Soins Intensifs, Centre de Recherche du Centre Intégré de Santé et de Services Sociaux de Chaudière-Appalaches, Université Laval, Québec City, Québec, Canada
| | - David Birnie
- Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Bjug Borgundvaag
- Division of Emergency Medicine, University of Toronto, Schwartz/Reisman Emergency Medicine Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Gregory Clark
- Department of Emergency Medicine, McGill University Health Centre, Montréal, Québec, Canada
| | - Philip Davis
- Department of Emergency Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | - Corinne Hohl
- Department of Emergency Medicine, Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bernard Mathieu
- Département de Médecine de Famille et de Médecine d'Urgence, Université de Montréal, Montréal, Québec, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Eric Mercier
- Department of Emergency Medicine, Centre for Clinical Epidemiology and Evaluation, Université Laval, Québec City, Québec, Canada; Département de Médecine Familiale et de Médecine d'Urgence, Centre de Recherche du CHU de Québec, Université Laval, Québec City, Québec, Canada
| | - Judy Morris
- Département de Médecine de Famille et de Médecine d'Urgence, Université de Montréal, Montréal, Québec, Canada
| | - Ratika Parkash
- Division of Cardiology, Department of Medicine, Dalhousie University, Dartmouth, Nova Scotia, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Brian H Rowe
- Department of Emergency Medicine, and School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | | | - Frank Scheuermeyer
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marco L A Sivilotti
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
| | - Alain Vadeboncoeur
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
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16
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Impact of Atrial Fibrillation Case Volume in the Emergency Department on Early and Late Outcomes of Patients With New Atrial Fibrillation. Ann Emerg Med 2021; 78:242-252. [PMID: 34325859 DOI: 10.1016/j.annemergmed.2021.03.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 01/23/2021] [Accepted: 02/10/2021] [Indexed: 12/20/2022]
Abstract
STUDY OBJECTIVE To define the association between atrial fibrillation case volume in the emergency department and death or all-cause hospitalization at 30 days and 1 year in patients with new atrial fibrillation. Secondary objectives examined repeat ED visits and the management of atrial fibrillation within 90 days. METHODS We identified all adults presenting to an ED in Alberta, Canada, with a new primary diagnosis of atrial fibrillation/flutter between 2009 and 2015 using International Classification of Diseases, 10th Revision code I48. Volume was classified in tertiles weighted by annual ED number of atrial fibrillation cases. The association between volume and outcomes was evaluated using generalized linear mixed models, adjusting for prognostically important covariates as fixed effects and ED as a random effect to account for potential clustering within EDs. RESULTS The tertiles consisted of 4 high, 9 medium, and 68 low atrial fibrillation volume EDs, with 4,217, 4,193, and 4,112 patients, respectively. Volume was not independently associated with the primary outcome or individual components. However, medium- and high-volume EDs had fewer repeat ED visits at 30 days (respective adjusted odds ratio [aOR] 0.75 [95% confidence interval {CI} 0.66 to 0.87] and 0.64 [0.52 to 0.79]) and 1 year (respective aOR 0.77 [95% CI 0.67 to 0.90] and 0.71 [0.56 to 0.90]). Fewer patients were admitted from medium- (37.1%) and high- (32.0%) compared with low-volume (39.5%) EDs. Patients attending medium- and high-volume EDs were more likely to be cardioverted (aOR 3.28 [95% CI 1.94 to 5.53] and 3.81 [1.39 to 10.48] for medium- and high-volume EDs, respectively). CONCLUSION Treatment in higher volume EDs was associated with significantly lower admission rates and repeat ED visits but no difference in survival.
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17
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RAFF-3 Trial: A Stepped-Wedge Cluster Randomized Trial to Improve Care of Acute Atrial Fibrillation and Flutter in the Emergency Department. Can J Cardiol 2021; 37:1569-1577. [PMID: 34217808 DOI: 10.1016/j.cjca.2021.06.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 06/21/2021] [Accepted: 06/23/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND We sought to improve care of patients with acute atrial fibrillation (AF) and flutter (AFL) in the emergency department (ED) by implementing the CAEP AAFF Best Practice Checklist. METHODS We conducted a stepped-wedge cluster randomized trial at 11 large community and academic hospital EDs, in five Canadian provinces and enrolled consecutive AF/AFL patients. The study intervention was the introduction of the CAEP Checklist using a knowledge translation-implementation approach that included behavior change techniques and organization/system level strategies. The primary outcome was length of stay in ED and secondary outcomes were discharge home, use of rhythm control, adverse events, and 30-day status. Analysis used mixed effects regression adjusting for covariates. RESULTS Patient visits in the control (N=314) and intervention (N=404) periods were similar with mean age 62.9, 54% male, 71% onset <12 hours, and 86% atrial fibrillation, 14% atrial flutter. We observed a reduction in length of stay of 20.9% (95% CI 5.5 to 33.8%, P=0.01), an increase in use of rhythm control (adjusted odds ratio (OR 4.5, 1.8-11.6; P=0.002), and decrease in use of rate control medications (OR 0.5, 0.2 to 0.9; P=0.02). There was no change in adverse events and no strokes or deaths by 30 days. CONCLUSIONS The RAFF-3 Trial led to optimized care of AF/AFL patients with decreased ED lengths of stay, increased ED rhythm control by drug or electricity, and no increase in adverse events. Early cardioversion allows AF/AFL patients to quickly resume normal activities. CLINICALTRIALS. GOV IDENTIFIER NCT03627143.
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18
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deSouza IS, Tadrous M, Sexton T, Benabbas R, Carmelli G, Sinert R. Pharmacologic cardioversion of recent-onset atrial fibrillation: a systematic review and network meta-analysis. Europace 2021; 22:854-869. [PMID: 32176779 DOI: 10.1093/europace/euaa024] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 01/21/2020] [Indexed: 12/21/2022] Open
Abstract
AIMS We sought to identify the most effective antidysrhythmic drug for pharmacologic cardioversion of recent-onset atrial fibrillation (AF). METHODS AND RESULTS We searched MEDLINE, Embase, and Web of Science from inception to March 2019, limited to human subjects and English language. We also searched for unpublished data. We limited studies to randomized controlled trials that enrolled adult patients with AF ≤ 48 h and compared antidysrhythmic agents, placebo, or control. We determined these outcomes prior to data extraction: (i) rate of conversion to sinus rhythm within 24 h, (ii) time to cardioversion to sinus rhythm, (iii) rate of significant adverse events, and (iv) rate of thromboembolism within 30 days. We extracted data according to PRISMA-NMA and appraised selected trials using the Cochrane review handbook. The systematic review initially identified 640 studies; 30 met inclusion criteria. Twenty-one trials that randomized 2785 patients provided efficacy data for the conversion rate outcome. Bayesian network meta-analysis using a random-effects model demonstrated that ranolazine + amiodarone intravenous (IV) [odds ratio (OR) 39.8, 95% credible interval (CrI) 8.3-203.1], vernakalant (OR 22.9, 95% CrI 3.7-146.3), flecainide (OR 16.9, 95% CrI 4.1-73.3), amiodarone oral (OR 10.2, 95% CrI 3.1-36.0), ibutilide (OR 7.9, 95% CrI 1.2-52.5), amiodarone IV (OR 5.4, 95% CrI 2.1-14.6), and propafenone (OR 4.1, 95% CrI 1.7-10.5) were associated with significantly increased likelihood of conversion within 24 h when compared to placebo/control. Overall quality was low, and the network exhibited inconsistency. Probabilistic analysis ranked vernakalant and flecainide high and propafenone and amiodarone IV low. CONCLUSION For pharmacologic cardioversion of recent-onset AF within 24 h, there is insufficient evidence to determine which treatment is superior. Vernakalant and flecainide may be relatively more efficacious agents. Propafenone and IV amiodarone may be relatively less efficacious. Further high-quality study is necessary.
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Affiliation(s)
- Ian S deSouza
- Department of Emergency Medicine, SUNY Downstate Health Sciences University, Brooklyn, New York, NY 11203, USA.,Department of Emergency Medicine, Kings County Hospital Center, 451 Clarkson Avenue, Brooklyn, NY 11203, USA
| | - Mina Tadrous
- Women's College Research Institute, Women's College Hospital, 76 Grenville St, Toronto, ON, M5S 1B2, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, ON M5S 3M2, Canada
| | - Theresa Sexton
- Department of Emergency Medicine, SUNY Downstate Health Sciences University, Brooklyn, New York, NY 11203, USA.,Department of Emergency Medicine, Kings County Hospital Center, 451 Clarkson Avenue, Brooklyn, NY 11203, USA
| | - Roshanak Benabbas
- Department of Emergency Medicine, SUNY Downstate Health Sciences University, Brooklyn, New York, NY 11203, USA.,Department of Emergency Medicine, Kings County Hospital Center, 451 Clarkson Avenue, Brooklyn, NY 11203, USA
| | - Guy Carmelli
- Department of Emergency Medicine, SUNY Downstate Health Sciences University, Brooklyn, New York, NY 11203, USA
| | - Richard Sinert
- Department of Emergency Medicine, SUNY Downstate Health Sciences University, Brooklyn, New York, NY 11203, USA.,Department of Emergency Medicine, Kings County Hospital Center, 451 Clarkson Avenue, Brooklyn, NY 11203, USA
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Calder LA, Perry J, Yan JW, De Gorter R, Sivilotti MLA, Eagles D, Myslik F, Borgundvaag B, Émond M, McRae AD, Taljaard M, Thiruganasambandamoorthy V, Cheng W, Forster AJ, Stiell IG. Adverse Events Among Emergency Department Patients With Cardiovascular Conditions: A Multicenter Study. Ann Emerg Med 2021; 77:561-574. [PMID: 33612283 DOI: 10.1016/j.annemergmed.2020.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE We aim to determine incidence and type of adverse events (adverse outcomes related to emergency care) among emergency department (ED) patients discharged with recent-onset atrial fibrillation, acute heart failure, and syncope. METHODS This 5-year prospective cohort study included high-acuity adult patients discharged with the 3 sentinel diagnoses from 6 tertiary care Canadian EDs. We screened all ED visits for eligibility and performed telephone interviews 14 days postdischarge to identify flagged outcomes: death, hospital admission, return ED visit, health care provider visit, and new or worsening symptoms. We created case summaries describing index ED visit and flagged outcomes, and trained emergency physicians reviewed case summaries to identify adverse events. We reported adverse event incidence and rates with 95% confidence intervals and contributing factor themes. RESULTS Among 4,741 subjects (mean age 70.2 years; 51.2% men), we observed 170 adverse events (3.6 per 100 patients; 95% confidence interval 3.1 to 4.2). Patients discharged with acute heart failure were most likely to experience adverse events (5.3%), followed by those with atrial fibrillation (2.0%) and syncope (0.8%). We noted variation in absolute adverse event rates across sites from 0.7 to 6.0 per 100 patients. The most common adverse event types were management issues, diagnostic issues, and unsafe disposition decisions. Frequent contributing factor themes included failure to recognize underlying causes and inappropriate management of dual diagnoses. CONCLUSION Among adverse events after ED discharge for patients with these 3 sentinel cardiovascular diagnoses, we identified quality improvement opportunities such as strengthening dual diagnosis detection and evidence-based clinical practice guideline adherence.
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Affiliation(s)
- Lisa A Calder
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Jeffrey Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Justin W Yan
- Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, Lawson Health Research Institute, London, Ontario, Canada
| | - Ria De Gorter
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Marco L A Sivilotti
- Departments of Emergency Medicine and Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Frank Myslik
- Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, Lawson Health Research Institute, London, Ontario, Canada
| | - Bjug Borgundvaag
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marcel Émond
- Département de médecine Familiale et d'Urgence, Université Laval, Québec City, Quebec, Canada
| | - Andrew D McRae
- Departments of Emergency Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Wei Cheng
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Alan J Forster
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
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20
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Kea B, Warton EM, Ballard DW, Mark DG, Reed ME, Rauchwerger AS, Offerman SR, Chettipally UK, Ramos PC, Le DD, Glaser DS, Vinson DR. Predictors of Acute Atrial Fibrillation and Flutter Hospitalization across 7 U.S. Emergency Departments: A Prospective Study. J Atr Fibrillation 2021; 13:2355. [PMID: 34950330 PMCID: PMC8691349 DOI: 10.4022/jafib.2355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/12/2020] [Accepted: 01/05/2021] [Indexed: 11/10/2022]
Abstract
INTRODUCTION International rates of hospitalization for atrial fibrillation and flutter (AFF) from the emergency department (ED) vary widely without clear evidence to guide the identification of high-risk patients requiring inpatient management. We sought to determine (1) variation in hospital admission and (2) modifiable factors associated with hospitalization of AFF patients within a U.S. integrated health system. METHODS This multicenter prospective observational study of health plan members with symptomatic AFF was conducted using convenience sampling in 7 urban community EDs from 05/2011 to 08/2012. Prospective data collection included presenting symptoms, characteristics of atrial dysrhythmia, ED physician impression of hemodynamic instability, comorbid diagnoses, ED management, and ED discharge rhythm. All centers had full-time on-call cardiology consultation available. Additional variables were extracted from the electronic health record. We identified factors associated with hospitalization and included predictors in a multivariate Poisson Generalized Estimating Equations regression model to estimate adjusted relative risks while accounting for clustering by physician. RESULTS Among 1,942 eligible AFF patients, 1,074 (55.3%) were discharged home and 868 (44.7%) were hospitalized. Hospitalization rates ranged from 37.4% to 60.4% across medical centers. After adjustment, modifiable factors associated with increased hospital admission from the ED included non-sinus rhythm at ED discharge, no attempted cardioversion, and heart rate reduction. DISCUSSION Within an integrated health system, we found significant variation in AFF hospitalization rates and identified several modifiable factors associated with hospital admission. Standardizing treatment goals that specifically address best practices for ED rate reduction and rhythm control may reduce hospitalizations.
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Affiliation(s)
- Bory Kea
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health and Science University, Portland, Oregon
| | - E Margaret Warton
- Kaiser Permanente Northern California Division of Research, Oakland, California
| | - Dustin W Ballard
- Kaiser Permanente Northern California Division of Research, Oakland, California
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente San Rafael Medical Center, San Rafael, California
| | - Dustin G Mark
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente Oakland Medical Center, Oakland, California
| | - Mary E Reed
- Kaiser Permanente Northern California Division of Research, Oakland, California
| | - Adina S Rauchwerger
- Kaiser Permanente Northern California Division of Research, Oakland, California
| | - Steven R Offerman
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente South Sacramento Medical Center, Sacramento, California
| | - Uli K Chettipally
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente South San Francisco Medical Center, South San Francisco, California
| | - Patricia C Ramos
- Kaiser Permanente Sunnyside Medical Center, Northwest Permanente Physicians and Surgeons, Department of Emergency Medicine, Portland, Oregon
| | - Daphne D Le
- University of California, Berkeley, California
| | - David S Glaser
- Sisters of Charity of Leavenworth St. Joseph Hospital, Department of Emergency Medicine, Denver, Colorado
| | - David R Vinson
- Kaiser Permanente Northern California Division of Research, Oakland, California
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente Sacramento Medical Center, Sacramento, California
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21
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Cimino JJ. Putting the "why" in "EHR": capturing and coding clinical cognition. J Am Med Inform Assoc 2021; 26:1379-1384. [PMID: 31407781 PMCID: PMC6798564 DOI: 10.1093/jamia/ocz125] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 06/21/2019] [Accepted: 06/25/2019] [Indexed: 12/02/2022] Open
Abstract
Complaints about electronic health records, including information overload, note bloat, and alert fatigue, are frequent topics of discussion. Despite substantial effort by researchers and industry, complaints continue noting serious adverse effects on patient safety and clinician quality of life. I believe solutions are possible if we can add information to the record that explains the “why” of a patient’s care, such as relationships between symptoms, physical findings, diagnostic results, differential diagnoses, therapeutic plans, and goals. While this information may be present in clinical notes, I propose that we modify electronic health records to support explicit representation of this information using formal structure and controlled vocabularies. Such information could foster development of more situation-aware tools for data retrieval and synthesis. Informatics research is needed to understand what should be represented, how to capture it, and how to benefit those providing the information so that their workload is reduced.
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Affiliation(s)
- James J Cimino
- Informatics Institute, University of Alabama at Birmingham, Birmingham, Alabama, USA
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22
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Stiell IG, Sivilotti MLA, Taljaard M, Birnie D, Vadeboncoeur A, Hohl CM, McRae AD, Morris J, Mercier E, Macle L, Brison RJ, Thiruganasambandamoorthy V, Rowe BH, Borgundvaag B, Clement CM, Brinkhurst J, Brown E, Nemnom MJ, Wells GA, Perry JJ. A randomized, controlled comparison of electrical versus pharmacological cardioversion for emergency department patients with acute atrial flutter. CAN J EMERG MED 2021; 23:314-324. [PMID: 33959925 DOI: 10.1007/s43678-020-00067-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 12/09/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Acute atrial flutter has one-tenth the prevalence of acute atrial fibrillation in the emergency department (ED) but shares many management strategies. Our aim was to compare conversion from acute atrial flutter to sinus rhythm between pharmacological cardioversion followed by electrical cardioversion (Drug-Shock), and electrical cardioversion alone (Shock-Only). METHODS We conducted a randomized, blinded, placebo-controlled comparison of attempted pharmacological cardioversion with IV procainamide followed by electrical cardioversion if necessary, and placebo infusion followed by electrical cardioversion. We enrolled stable patients with a primary diagnosis of acute acute atrial flutter at 11 academic EDs. The primary outcome was conversion to normal sinus rhythm. FINDINGS From July 2013 to October 2018, we enrolled 76 patients, and none were lost to follow-up. Comparing the Drug-Shock to the Shock-Only group, conversion to sinus rhythm occurred in 33 (100%) versus 40 (93%) (absolute difference 7.0%; 95% CI - 0.6 to 14.6; P = 0.25). Median time to conversion from start of infusion in the Drug-Shock group was 24 min (IQR 21-82) but only 9 (27%) cases were converted with IV procainamide. Patients in both groups had similar outcomes at 14 days; there were no strokes or deaths. INTERPRETATION This trial found that the Drug-Shock strategy is potentially superior but that either approach to immediate rhythm control in the ED for patients with acute acute atrial flutter is highly effective, rapid, and safe in restoring sinus rhythm and allowing patients to go home and return to normal activities. Unlike the case of atrial fibrillation, we found that IV procainamide alone was infrequently effective.
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Affiliation(s)
- Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada. .,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | | | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - David Birnie
- Division of Cardiology, University of Ottawa Heart Institute, 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
| | - 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
| | - Laurent Macle
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, QC, Canada
| | - Robert J Brison
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
| | - Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Brian H Rowe
- Department of Emergency Medicine and School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Bjug Borgundvaag
- Division of Emergency Medicine, Schwartz/Reisman Emergency Medicine Institute, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Catherine M Clement
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Jennifer Brinkhurst
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Erica Brown
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Marie-Joe Nemnom
- Clinical Epidemiology Program, 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, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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23
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Pluymaekers NAHA, Dudink EAMP, Weijs B, Vernooy K, Hartgerink DEJ, Jacobs JS, Erküner Ö, Marcks NGHM, van Cauteren YJM, Dinh T, Ter Bekke RMA, Sels JEMW, Delnoij TSR, Geyik Z, Driessen RGH, Linz DK, den Uijl DW, Crijns HJGM, Luermans JGLM. Clinical determinants of early spontaneous conversion to sinus rhythm in patients with atrial fibrillation. Neth Heart J 2021; 29:255-261. [PMID: 33410120 PMCID: PMC8062641 DOI: 10.1007/s12471-020-01528-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2020] [Indexed: 01/26/2023] Open
Abstract
Background The current standard of care for acute atrial fibrillation (AF) focuses primarily on immediate restoration of sinus rhythm by cardioversion, although AF often terminates spontaneously. Objective To identify determinants of early spontaneous conversion (SCV) in patients presenting at the emergency department (ED) because of AF. Methods An observational study was performed of patients who visited the ED with documented AF between July 2014 and December 2016. The clinical characteristics and demographics of patients with and without SCV were compared. Results We enrolled 943 patients (age 69 ± 12 years, 47% female). SCV occurred within 3 h of presentation in 158 patients (16.8%). Logistic regression analysis showed that duration of AF <24 h [odds ratio (OR) 7.7, 95% confidence interval (CI) 3.5–17.2, p < 0.001], left atrial volume index <42 ml/m2 (OR 1.8, 95% CI 1.2–2.8, p = 0.010), symptoms of near-collapse at presentation (OR 2.4, 95% CI 1.2–5.1, p = 0.018), a lower body mass index (BMI) (OR 0.9, 95% CI 0.91–0.99, p = 0.028), a longer QTc time during AF (OR 1.01, 95% CI 1.0–1.02, p = 0.002) and first-detected AF (OR 2.5, 95% CI 1.6–3.9, p < 0.001) were independent determinants of early SCV. Conclusion Early spontaneous conversion of acute AF occurs in almost one-sixth of admitted patients during a short initial observation in the ED. Spontaneous conversion is most likely to occur in patients with first-onset, short-duration AF episodes, lower BMI, and normal left atrial size.
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Affiliation(s)
- N A H A Pluymaekers
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.
| | - E A M P Dudink
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - B Weijs
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - K Vernooy
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - D E J Hartgerink
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - J S Jacobs
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Ö Erküner
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - N G H M Marcks
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Y J M van Cauteren
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - T Dinh
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - R M A Ter Bekke
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - J E M W Sels
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
- Department of Intensive Care Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - T S R Delnoij
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
- Department of Intensive Care Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Z Geyik
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
- Department of Intensive Care Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - R G H Driessen
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
- Department of Intensive Care Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - D K Linz
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - D W den Uijl
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - H J G M Crijns
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - J G L M Luermans
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
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Stiell IG, Sivilotti MLA, Perry JJ. Emergency department cardioversion of acute atrial fibrillation - Authors' reply. Lancet 2020; 396:886. [PMID: 32979975 DOI: 10.1016/s0140-6736(20)31308-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 05/28/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Ian G Stiell
- Department of Emergency Medicine and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON K1Y 4E9, Canada.
| | | | - Jeffrey J Perry
- Department of Emergency Medicine and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON K1Y 4E9, Canada
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25
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Christians BE, Solie CJ, Swanson MB, Harland KK, Fairfield C, Wallace KL, Mohr NM. The Iowa less aggressive protocol: A mixed-methods study on the novel treatment protocol of atrial fibrillation. Am J Emerg Med 2020; 45:439-445. [PMID: 33039220 DOI: 10.1016/j.ajem.2020.09.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/26/2020] [Accepted: 09/20/2020] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES Atrial fibrillation is the most common cardiac dysrhythmia in the United States. Our aim was to determine if a novel protocol for management of atrial fibrillation was feasible to implement in an emergency department (ED). Interviews were conducted with ED physicians and physician assistants to identify themes in relation to the clinical use and impleon of the protocol. METHODS A novel protocol was developed by a multi-disciplinary team and implemented in an academic ED. The protocol used cardiac computed tomography (CT) to rule out left atrial thrombus in patients with greater than 12 h of symptoms and high risk of thromboembolism, or any patient with greater than 48 h of symptoms. Patients who underwent cardiac CT or electrical cardioversion were followed up at 30 days via telephone to monitor for recurrence or adverse thromboembolic events. Providers were interviewed to identify themes regarding protocol usage, barriers to its use, and future changes to increase utilization. RESULTS Patients with atrial fibrillation in the ED were eligible for inclusion. Twenty-nine patients were treated using the protocol. Seven patients (24%) underwent cardiac CT prior to electrical cardioversion. Cardioversion success rate was 83%, with 69% of patients discharged home. Thirty-day follow-up was completed on 25 patients (86%). Six patients (24%) had reoccurrence of atrial fibrillation requiring subsequent cardioversion. No patients experienced stroke or thromboembolic event. Interviews were conducted with 14 providers. Usage barriers included time, availability, and additional work-up. Six subthemes were identified for future changes including EMR order set, frequent reminders, increased education, increased awareness, activation energy, and EMR pop-ups. CONCLUSION The Iowa Less Aggressive Protocol is a novel treatment protocol for the ED management of atrial fibrillation that was feasible to implement and use. Providers viewed the protocol favorably and identified areas of improvement for future use.
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Affiliation(s)
- Benjamin E Christians
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242, USA.
| | - Christopher J Solie
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242, USA; Emergency Physicians and Consultants, P.A. 500 S Maple St, Waconia, MN 55387, USA.
| | - Morgan B Swanson
- University of Iowa Carver College of Medicine, 375 Newton Rd, Iowa City, IA 52242, USA.
| | - Karisa K Harland
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242, USA.
| | - Catherine Fairfield
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242, USA.
| | - Kelli L Wallace
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242, USA.
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242, USA; Department of Anesthesia, Division of Critical Care, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242, USA.
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26
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Atzema CL, Jackevicius CA, Chong A, Dorian P, Ivers NM, Parkash R, Austin PC. Prescribing of oral anticoagulants in the emergency department and subsequent long-term use by older adults with atrial fibrillation. CMAJ 2020; 191:E1345-E1354. [PMID: 31818927 DOI: 10.1503/cmaj.190747] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2019] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Patients with atrial fibrillation frequently seek emergency care. Rates of guideline-concordant oral anticoagulant therapy for stroke prevention are suboptimal in the community. We assessed the association between prescribing of oral anticoagulants in the emergency department (relative to referral to a longitudinal care provider for treatment initiation) and long-term use of oral anticoagulants. METHODS This retrospective cohort study performed at 15 hospitals in Ontario, Canada, involved patients aged 65 years or older who visited the emergency department between 2009 and 2014, who had a primary diagnosis of atrial fibrillation, were discharged home, and were eligible for and willing to take stroke-prevention therapy. We used inverse probability-of-treatment weighting based on the propensity score to compare patients who were and were not given a prescription for an oral anticoagulant. The primary outcome was a prescription fill for an oral anticoagulant 6 months later. Secondary outcomes included a prescription fill at 1 year, all-cause mortality, and strokes or bleeding events leading to hospital admission. RESULTS Of 2132 eligible patients, 402 (18.9%) were given a prescription for an oral anticoagulant in the emergency department. After weighting, 67.8% of these patients had filled a prescription for an oral anticoagulant at 6 months versus 37.2% of those who did not receive a prescription in the emergency department (absolute risk increase [ARI] 30.6%, number needed to treat [NNT] 3). At 1 year, the ARI was 23.2% and the NNT was 4. Rates of death, stroke and bleeding events did not differ significantly. INTERPRETATION In patients with atrial fibrillation who were eligible for stroke prevention, prescribing an oral anticoagulant in the emergency department was associated with substantially higher long-term use of oral anticoagulants compared with deferring to the longitudinal care provider to initiate this therapy. Physicians working in the emergency department should consider initiating oral anticoagulation in eligible patients who are being discharged to home.
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Affiliation(s)
- Clare L Atzema
- ICES Central (Atzema, Jackevicius, Chong, Ivers, Austin); Division of Emergency Medicine, Department of Medicine (Atzema), Division of Cardiology, Department of Medicine (Dorian), Department of Family Medicine (Ivers) and Institute for Health Policy, Management and Evaluation (Jackevicius, Dorian, Ivers, Austin), University of Toronto; Sunnybrook Health Sciences Centre (Atzema); Women's College Hospital (Ivers); St. Michael's Hospital (Dorian), Toronto, Ont.; Western University of Health Sciences, Pomona, Calif. (Jackevicius); QEII Health Sciences Centre (Parkash), Halifax, NS
| | - Cynthia A Jackevicius
- ICES Central (Atzema, Jackevicius, Chong, Ivers, Austin); Division of Emergency Medicine, Department of Medicine (Atzema), Division of Cardiology, Department of Medicine (Dorian), Department of Family Medicine (Ivers) and Institute for Health Policy, Management and Evaluation (Jackevicius, Dorian, Ivers, Austin), University of Toronto; Sunnybrook Health Sciences Centre (Atzema); Women's College Hospital (Ivers); St. Michael's Hospital (Dorian), Toronto, Ont.; Western University of Health Sciences, Pomona, Calif. (Jackevicius); QEII Health Sciences Centre (Parkash), Halifax, NS
| | - Alice Chong
- ICES Central (Atzema, Jackevicius, Chong, Ivers, Austin); Division of Emergency Medicine, Department of Medicine (Atzema), Division of Cardiology, Department of Medicine (Dorian), Department of Family Medicine (Ivers) and Institute for Health Policy, Management and Evaluation (Jackevicius, Dorian, Ivers, Austin), University of Toronto; Sunnybrook Health Sciences Centre (Atzema); Women's College Hospital (Ivers); St. Michael's Hospital (Dorian), Toronto, Ont.; Western University of Health Sciences, Pomona, Calif. (Jackevicius); QEII Health Sciences Centre (Parkash), Halifax, NS
| | - Paul Dorian
- ICES Central (Atzema, Jackevicius, Chong, Ivers, Austin); Division of Emergency Medicine, Department of Medicine (Atzema), Division of Cardiology, Department of Medicine (Dorian), Department of Family Medicine (Ivers) and Institute for Health Policy, Management and Evaluation (Jackevicius, Dorian, Ivers, Austin), University of Toronto; Sunnybrook Health Sciences Centre (Atzema); Women's College Hospital (Ivers); St. Michael's Hospital (Dorian), Toronto, Ont.; Western University of Health Sciences, Pomona, Calif. (Jackevicius); QEII Health Sciences Centre (Parkash), Halifax, NS
| | - Noah M Ivers
- ICES Central (Atzema, Jackevicius, Chong, Ivers, Austin); Division of Emergency Medicine, Department of Medicine (Atzema), Division of Cardiology, Department of Medicine (Dorian), Department of Family Medicine (Ivers) and Institute for Health Policy, Management and Evaluation (Jackevicius, Dorian, Ivers, Austin), University of Toronto; Sunnybrook Health Sciences Centre (Atzema); Women's College Hospital (Ivers); St. Michael's Hospital (Dorian), Toronto, Ont.; Western University of Health Sciences, Pomona, Calif. (Jackevicius); QEII Health Sciences Centre (Parkash), Halifax, NS
| | - Ratika Parkash
- ICES Central (Atzema, Jackevicius, Chong, Ivers, Austin); Division of Emergency Medicine, Department of Medicine (Atzema), Division of Cardiology, Department of Medicine (Dorian), Department of Family Medicine (Ivers) and Institute for Health Policy, Management and Evaluation (Jackevicius, Dorian, Ivers, Austin), University of Toronto; Sunnybrook Health Sciences Centre (Atzema); Women's College Hospital (Ivers); St. Michael's Hospital (Dorian), Toronto, Ont.; Western University of Health Sciences, Pomona, Calif. (Jackevicius); QEII Health Sciences Centre (Parkash), Halifax, NS
| | - Peter C Austin
- ICES Central (Atzema, Jackevicius, Chong, Ivers, Austin); Division of Emergency Medicine, Department of Medicine (Atzema), Division of Cardiology, Department of Medicine (Dorian), Department of Family Medicine (Ivers) and Institute for Health Policy, Management and Evaluation (Jackevicius, Dorian, Ivers, Austin), University of Toronto; Sunnybrook Health Sciences Centre (Atzema); Women's College Hospital (Ivers); St. Michael's Hospital (Dorian), Toronto, Ont.; Western University of Health Sciences, Pomona, Calif. (Jackevicius); QEII Health Sciences Centre (Parkash), Halifax, NS
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27
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Russak AJ, Chaudhry F, De Freitas JK, Baron G, Chaudhry FF, Bienstock S, Paranjpe I, Vaid A, Ali M, Zhao S, Somani S, Richter F, Bawa T, Levy PD, Miotto R, Nadkarni GN, Johnson KW, Glicksberg BS. Machine Learning in Cardiology-Ensuring Clinical Impact Lives Up to the Hype. J Cardiovasc Pharmacol Ther 2020; 25:379-390. [PMID: 32495652 DOI: 10.1177/1074248420928651] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Despite substantial advances in the study, treatment, and prevention of cardiovascular disease, numerous challenges relating to optimally screening, diagnosing, and managing patients remain. Simultaneous improvements in computing power, data storage, and data analytics have led to the development of new techniques to address these challenges. One powerful tool to this end is machine learning (ML), which aims to algorithmically identify and represent structure within data. Machine learning's ability to efficiently analyze large and highly complex data sets make it a desirable investigative approach in modern biomedical research. Despite this potential and enormous public and private sector investment, few prospective studies have demonstrated improved clinical outcomes from this technology. This is particularly true in cardiology, despite its emphasis on objective, data-driven results. This threatens to stifle ML's growth and use in mainstream medicine. We outline the current state of ML in cardiology and outline methods through which impactful and sustainable ML research can occur. Following these steps can ensure ML reaches its potential as a transformative technology in medicine.
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Affiliation(s)
- Adam J Russak
- Department of Internal Medicine, Mount Sinai Hospital, New York, NY, USA.,Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Farhan Chaudhry
- Department of Emergency Medicine and Integrative Biosciences Center, Wayne State University, Detroit, MI, USA
| | - Jessica K De Freitas
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Garrett Baron
- Department of Emergency Medicine and Integrative Biosciences Center, Wayne State University, Detroit, MI, USA
| | - Fayzan F Chaudhry
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Solomon Bienstock
- Department of Internal Medicine, Mount Sinai Hospital, New York, NY, USA
| | - Ishan Paranjpe
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Akhil Vaid
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mohsin Ali
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Shan Zhao
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sulaiman Somani
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Felix Richter
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Tejeshwar Bawa
- Department of Emergency Medicine and Integrative Biosciences Center, Wayne State University, Detroit, MI, USA
| | - Phillip D Levy
- Department of Emergency Medicine and Integrative Biosciences Center, Wayne State University, Detroit, MI, USA
| | - Riccardo Miotto
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Girish N Nadkarni
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Division of Nephrology, Mount Sinai Hospital, New York, NY, USA.,Division of Cardiology, Mount Sinai Hospital, New York, NY, USA.,Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kipp W Johnson
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Benjamin S Glicksberg
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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28
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Bond C, Morgenstern J, Heitz C, Milne WK. Hot Off the Press: Chemical Versus Electrical Cardioversion for Atrial Fibrillation. Acad Emerg Med 2020; 27:333-335. [PMID: 31626719 DOI: 10.1111/acem.13874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 10/15/2019] [Indexed: 11/29/2022]
Abstract
Atrial fibrillation (AF) is a significant dysrhythmia that often requires treatment in the emergency department (ED). This can be performed with rhythm control using electrical or chemical cardioversion or with rate control. There is widespread variation in management of AF within Canada and worldwide. This study focuses on rhythm control techniques, comparing ED length of stay when using an electrical-first strategy versus a chemical-first strategy of cardioversion.
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Affiliation(s)
- Christopher Bond
- From the, Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | | | - William K Milne
- and the, Department of Emergency Medicine, University of Western Ontario, Goderich, Ontario, Canada
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29
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deSouza IS, Tadrous M, Sexton T, Benabbas R, Carmelli G, Sinert R. Pharmacologic Cardioversion of Recent-Onset Atrial Fibrillation and Flutter in the Emergency Department: A Systematic Review and Network Meta-analysis. Ann Emerg Med 2020; 76:14-30. [PMID: 32173135 DOI: 10.1016/j.annemergmed.2020.01.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 12/21/2019] [Accepted: 01/07/2020] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE We conduct a systematic review and Bayesian network meta-analysis to indirectly compare and rank antidysrhythmic drugs for pharmacologic cardioversion of recent-onset atrial fibrillation and atrial flutter in the emergency department (ED). METHODS We searched MEDLINE, EMBASE, and Web of Science from inception to March 2019, limited to human subjects and English language. We also searched for unpublished data. We limited studies to randomized controlled trials that enrolled adult patients with recent-onset atrial fibrillation or atrial flutter and compared antidysrhythmic agents, placebo, or control. We determined these outcomes before data extraction: rate of conversion to sinus rhythm within 4 hours, time to cardioversion, rate of significant adverse events, and rate of thromboembolism within 30 days. We extracted data according to Preferred Reporting Items for Systematic Reviews and Meta-analyses network meta-analysis and appraised selected trials with the Cochrane review handbook. RESULTS The systematic review initially identified 640 studies; 19 met inclusion criteria. Eighteen trials that randomized 2,069 atrial fibrillation patients provided data for atrial fibrillation conversion rate outcome. Bayesian network meta-analysis using a random-effects model demonstrated that antazoline (odds ratio [OR] 24.9; 95% credible interval [CrI] 7.4 to 107.8), tedisamil (OR 12.0; 95% CrI 4.3 to 43.8), vernakalant (OR 7.5; 95% CrI 3.1 to 18.6), propafenone (OR 6.8; 95% CrI 3.6 to 13.8), flecainide (OR 6.1; 95% CrI 2.9 to 13.2), and ibutilide (OR 4.1; 95% CrI 1.8 to 9.6) were associated with increased likelihood of conversion within 4 hours compared with placebo or control. Overall quality was low, and the network exhibited inconsistency. CONCLUSION For pharmacologic cardioversion of recent-onset atrial fibrillation within a 4-hour ED visit, there is insufficient evidence to determine which treatment is superior. Several agents are associated with increased likelihood of conversion within 4 hours compared with placebo or control. Limited data preclude any recommendation for cardioversion of recent-onset atrial flutter. Further high-quality study is necessary.
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Affiliation(s)
- Ian S deSouza
- Department of Emergency Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY; Department of Emergency Medicine, Kings County Hospital Center, Brooklyn, NY.
| | - Mina Tadrous
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada; Women's College Research Institute, Women's College Hospital in Toronto, Toronto, Ontario, Canada
| | - Theresa Sexton
- Department of Emergency Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY; Department of Emergency Medicine, Kings County Hospital Center, Brooklyn, NY
| | - Roshanak Benabbas
- Department of Emergency Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY; Department of Emergency Medicine, Kings County Hospital Center, Brooklyn, NY
| | - Guy Carmelli
- Department of Emergency Medicine, Kings County Hospital Center, Brooklyn, NY
| | - Richard Sinert
- Department of Emergency Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY; Department of Emergency Medicine, Kings County Hospital Center, Brooklyn, NY
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30
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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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31
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Wong BM, Green MS, Stiell IG. Rate Control Management of Atrial Fibrillation With Rapid Ventricular Response in the Emergency Department. Can J Cardiol 2020; 36:509-517. [PMID: 31924453 DOI: 10.1016/j.cjca.2019.08.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 08/27/2019] [Accepted: 08/29/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND There exists limited evidence on managing atrial fibrillation (AF) with rapid ventricular response in the emergency department. We sought to better understand the burden of disease in patients with AF for whom rhythm control was not successful or not attempted and identify opportunities for improved care. METHODS We conducted a health records review of consecutive visits of patients with AF at 2 academic emergency departments. We included patients ≥ 18 years with AF, heart rate ≥ 100 beats per minute (bpm), and who were not successfully cardioverted or not attempted cardioversion. Outcomes were: (1) incidence given rate control, (2) management practices, (3) adverse events, (4) compliance with guidelines, and (5) outcomes. We performed descriptive statistics. RESULTS We included 665 visits, with mean age ± standard deviation 77.4 ± 12.9, female 51.6%, mean ± standard deviation heart rate 121.6 ± 17.4 bpm, AF status (permanent 53.4%; paroxysmal 29.5%; persistent 17.1%), admitted 61.4%. Of all cases, 147 (22.1%) had primary AF and 518 (77.9%) had a rapid rate secondary to a medical cause (heart failure 12.8%; pneumonia 11.7%; sepsis 8.4%). In 117 with primary AF given rate control, 59.0% had a final rate ≤ 100 bpm and 7.7% suffered adverse events. Suboptimal use of rate control occurred in 47.0% (agent 2.6%; route 27.4%; dosage 9.4%; timing 7.7%). At discharge, 11.5% with CHADS-65 risk factors were still not anticoagulated. CONCLUSIONS Most patients had a rapid rhythm secondary to a medical cause. There were a concerning number of adverse events related to suboptimal use of rate control. Better awareness of guidelines will ensure safer use of rate control.
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Affiliation(s)
- Brenton M Wong
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Martin S Green
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
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32
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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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33
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Atzema CL, Yu B, Schull MJ, Jackevicius CA, Ivers NM, Lee DS, Rochon PA, Austin PC. Association of Follow-Up Care With Long-Term Death and Subsequent Hospitalization in Patients With Atrial Fibrillation Who Receive Emergency Care in the Province of Ontario. Circ Arrhythm Electrophysiol 2019; 12:e006498. [DOI: 10.1161/circep.118.006498] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Currently, 11% of patients seen in the emergency department for atrial fibrillation die within 1 year of the visit. Our objective was to examine the association of rapid (within 3 days), early (7 days), and basic (30 days) outpatient physician follow-up with short- and long-term outcomes in patients with atrial fibrillation discharged from an emergency department.
Methods:
This retrospective cohort study included all adult patients discharged from one of the 163 emergency departments in Ontario, Canada with a primary diagnosis of atrial fibrillation, 2007 to 2014. We used a landmark analysis with propensity score matching, and logistic regression, to assess all-cause mortality and cardiovascular hospitalizations at 1 year and 90 days, 30-day return emergency visits, and 1-year oral anticoagulation prescription fills.
Results:
In the 10 657 patients with rapid follow-up care who were propensity score matched to a patient with follow-up between days 4 and 7, the hazard of a return emergency visit was reduced by 11% (HR, 0.89 [95% CI, 0.80–0.98]). It was not associated with mortality or hospitalization. In the 17 234 patients with early follow-up who were matched to a patient with care between days 8 and 30, the rate of 1-year mortality was 11% lower (HR, 0.89 [95% CI, 0.81–0.97]) and 1-year hospitalization was 6% lower (HR, 0.94 [95% CI, 0.89–1.00]). Relative to no 30-day care, basic follow-up care was associated with an increased hazard of 90-day hospitalization (HR, 1.32 [95% CI, 1.12–1.56]) but was no longer associated with mortality. In patients with early follow-up, the odds of filling an oral anticoagulation prescription a year later were 64% higher than those without it (OR, 1.64 [95% CI, 1.54–1.78]).
Conclusions:
Compared with follow-up care between days 8 and 30, follow-up within a week after discharge from an emergency department with atrial fibrillation was associated with a reduction in the rate of death and hospitalization within 1 year, an association that was not present with 30-day follow-up.
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Affiliation(s)
- Clare L. Atzema
- ICES, Toronto, ON (C.L.A., B.Y., M.J.S., C.A.J., N.M.I., D.S.L., P.A.R., P.C.A.)
- Division of Emergency Medicine (C.L.A., M.J.S.), University of Toronto, ON
- The Institute of Health Policy, Management and Evaluation (C.L.A., M.J.S., C.A.J., N.M.I., D.S.L., P.A.R., P.C.A.), University of Toronto, ON
- Sunnybrook Health Sciences Centre (C.L.A., M.J.S., P.C.A.), Toronto, ON, Canada
| | - Bing Yu
- ICES, Toronto, ON (C.L.A., B.Y., M.J.S., C.A.J., N.M.I., D.S.L., P.A.R., P.C.A.)
| | - Michael J. Schull
- ICES, Toronto, ON (C.L.A., B.Y., M.J.S., C.A.J., N.M.I., D.S.L., P.A.R., P.C.A.)
- Division of Emergency Medicine (C.L.A., M.J.S.), University of Toronto, ON
- The Institute of Health Policy, Management and Evaluation (C.L.A., M.J.S., C.A.J., N.M.I., D.S.L., P.A.R., P.C.A.), University of Toronto, ON
- Sunnybrook Health Sciences Centre (C.L.A., M.J.S., P.C.A.), Toronto, ON, Canada
| | - Cynthia A. Jackevicius
- ICES, Toronto, ON (C.L.A., B.Y., M.J.S., C.A.J., N.M.I., D.S.L., P.A.R., P.C.A.)
- The Institute of Health Policy, Management and Evaluation (C.L.A., M.J.S., C.A.J., N.M.I., D.S.L., P.A.R., P.C.A.), University of Toronto, ON
- University Health Network (C.A.J., D.S.L.), Toronto, ON, Canada
- Western University of Health Sciences, Pomona, CA (C.A.J.)
- The Veteran’s Affairs Greater Los Angeles Healthcare System, CA (C.A.J.)
| | - Noah M. Ivers
- ICES, Toronto, ON (C.L.A., B.Y., M.J.S., C.A.J., N.M.I., D.S.L., P.A.R., P.C.A.)
- Department of Family and Community Medicine (N.M.I.), University of Toronto, ON
- The Institute of Health Policy, Management and Evaluation (C.L.A., M.J.S., C.A.J., N.M.I., D.S.L., P.A.R., P.C.A.), University of Toronto, ON
- Women’s College Hospital (N.M.I., P.A.R.), Toronto, ON, Canada
| | - Douglas S. Lee
- ICES, Toronto, ON (C.L.A., B.Y., M.J.S., C.A.J., N.M.I., D.S.L., P.A.R., P.C.A.)
- Departments of Cardiology and Medicine (D.S.L.), University of Toronto, ON
- The Institute of Health Policy, Management and Evaluation (C.L.A., M.J.S., C.A.J., N.M.I., D.S.L., P.A.R., P.C.A.), University of Toronto, ON
- University Health Network (C.A.J., D.S.L.), Toronto, ON, Canada
| | - Paula A. Rochon
- ICES, Toronto, ON (C.L.A., B.Y., M.J.S., C.A.J., N.M.I., D.S.L., P.A.R., P.C.A.)
- The Institute of Health Policy, Management and Evaluation (C.L.A., M.J.S., C.A.J., N.M.I., D.S.L., P.A.R., P.C.A.), University of Toronto, ON
- Women’s College Hospital (N.M.I., P.A.R.), Toronto, ON, Canada
| | - Peter C. Austin
- ICES, Toronto, ON (C.L.A., B.Y., M.J.S., C.A.J., N.M.I., D.S.L., P.A.R., P.C.A.)
- The Institute of Health Policy, Management and Evaluation (C.L.A., M.J.S., C.A.J., N.M.I., D.S.L., P.A.R., P.C.A.), University of Toronto, ON
- Sunnybrook Health Sciences Centre (C.L.A., M.J.S., P.C.A.), Toronto, ON, Canada
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Ptaszek LM, Baugh CW, Lubitz SA, Ruskin JN, Ha G, Forsch M, DeOliveira SA, Baig S, Heist EK, Wasfy JH, Brown DF, Biddinger PD, Raja AS, Scirica B, White BA, Mansour M. Impact of a Multidisciplinary Treatment Pathway for Atrial Fibrillation in the Emergency Department on Hospital Admissions and Length of Stay: Results of a Multi-Center Study. J Am Heart Assoc 2019; 8:e012656. [PMID: 31510841 PMCID: PMC6818017 DOI: 10.1161/jaha.119.012656] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background Variability in the management of atrial fibrillation (AF) in the emergency department (ED) leads to avoidable hospital admissions and prolonged length of stay (LOS). In a retrospective single‐center study, a multidisciplinary AF treatment pathway was associated with a reduced hospital admission rate and reduced LOS. To assess the applicability of the AF pathway across institutions, we conducted a 2‐center study. Methods and Results We performed a prospective, 2‐stage study at 2 tertiary care hospitals. During the first stage, AF patients in the ED received routine care. During the second stage, AF patients received care according to the AF pathway. The primary study outcome was hospital admission rate. Secondary outcomes included ED LOS and inpatient LOS. We enrolled 104 consecutive patients in each stage. Patients treated using the AF pathway were admitted to the hospital less frequently than patients who received routine care (15% versus 55%; P<0.001). For admitted patients, average hospital LOS was shorter in the AF pathway cohort than in the routine care cohort (64 versus 105 hours, respectively; P=0.01). There was no significant difference in the average ED LOS between AF pathway and routine care cohorts (14 versus 12 hours, respectively; P=0.32). Conclusions In this prospective 2‐stage, 2‐center study, utilization of a multidisciplinary AF treatment pathway resulted in a 3.7‐fold reduction in admission rate and a 1.6‐fold reduction in average hospital LOS for admitted patients. Utilization of the AF pathway was not associated with a significant change in ED LOS.
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Affiliation(s)
- Leon M Ptaszek
- Cardiac Arrhythmia Service Massachusetts General Hospital Boston MA
| | | | - Steven A Lubitz
- Cardiac Arrhythmia Service Massachusetts General Hospital Boston MA
| | - Jeremy N Ruskin
- Cardiac Arrhythmia Service Massachusetts General Hospital Boston MA
| | - Grace Ha
- Cardiac Arrhythmia Service Massachusetts General Hospital Boston MA
| | - Margaux Forsch
- Cardiac Arrhythmia Service Massachusetts General Hospital Boston MA
| | | | - Samia Baig
- Cardiac Arrhythmia Service Massachusetts General Hospital Boston MA
| | - E Kevin Heist
- Cardiac Arrhythmia Service Massachusetts General Hospital Boston MA
| | - Jason H Wasfy
- Cardiology Division Massachusetts General Hospital Boston MA
| | - David F Brown
- Department of Emergency Medicine Massachusetts General Hospital Boston MA
| | - Paul D Biddinger
- Department of Emergency Medicine Massachusetts General Hospital Boston MA
| | - Ali S Raja
- Department of Emergency Medicine Massachusetts General Hospital Boston MA
| | - Benjamin Scirica
- Heart and Vascular Center Brigham and Women's Hospital Boston MA
| | - Benjamin A White
- Department of Emergency Medicine Massachusetts General Hospital Boston MA
| | - Moussa Mansour
- Cardiac Arrhythmia Service Massachusetts General Hospital Boston MA
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Scheuermeyer FX, Andolfatto G, Christenson J, Villa‐Roel C, Rowe B. A Multicenter Randomized Trial to Evaluate a Chemical-first or Electrical-first Cardioversion Strategy for Patients With Uncomplicated Acute Atrial Fibrillation. Acad Emerg Med 2019; 26:969-981. [PMID: 31423687 DOI: 10.1111/acem.13669] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Revised: 10/05/2018] [Accepted: 10/23/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Emergency department (ED) patients with uncomplicated atrial fibrillation (AF) of less than 48 hours may be safely managed with rhythm control. Although both chemical-first and electrical-first strategies have been advocated, there are no comparative effectiveness data to guide clinicians. METHODS At six urban Canadian centers, ED patients ages 18 to 75 with uncomplicated symptomatic AF of less than 48 hours and CHADS2 score of 0 or 1 were randomized using concealed allocation in a 1:1 ratio to one of the following strategies: 1) chemical cardioversion with procainamide infusion, followed by electrical countershock if unsuccessful; or 2) electrical cardioversion, followed by procainamide infusion if unsuccessful. The primary outcome was the proportion of patients discharged within 4 hours of arrival. Secondary outcomes included ED length-of-stay (LOS); prespecified ED-based adverse events; and 30-day ED revisits, hospitalizations, strokes, deaths, and quality of life (QoL). RESULTS Eighty-four patients were analyzed: 41 in the chemical-first group and 43 in the electrical-first group. Groups were balanced in terms of age, sex, vital signs, and CHADS2 scores. All patients were discharged home, with 83 (99%) in sinus rhythm. In the chemical-first group, 13 of 41 patients (32%) were discharged within 4 hours compared to 29 of 43 patients (67%) in the electrical-first group (p = 0.001). In the chemical-first group, the median ED LOS was 5.1 hours (interquartile range [IQR] = 3.5 to 5.9 hours) compared to 3.5 hours (IQR = 2.4 to 4.6 hours) in the electrical-first group, for a median difference of 1.2 hours (95% confidence interval = 0.4 to 2.0 hours, p < 0.001). No patients experienced stroke or death. All other outcomes, including adverse events, ED revisits, and QoL, were similar. CONCLUSION In uncomplicated ED AF patients managed with rhythm control, chemical-first and electrical-first strategies both appear to be successful and well tolerated; however, an electrical-first strategy results in a significantly shorter ED LOS.
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Affiliation(s)
- Frank X. Scheuermeyer
- Department of Emergency Medicine St Paul's Hospital and the University of British Columbia Vancouver BC
- Department of Emergency Medicine South Health Campus and the University of Calgary Calgary AB
| | - Gary Andolfatto
- Department of Emergency Medicine Lions Gate Hospital the University of British Columbia Vancouver BC
| | - Jim Christenson
- Department of Emergency Medicine St Paul's Hospital and the University of British Columbia Vancouver BC
| | - Cristina Villa‐Roel
- Department of Emergency Medicine University of Alberta Hospital and the University of Alberta Edmonton AB Canada
| | - Brian Rowe
- Department of Emergency Medicine University of Alberta Hospital and the University of Alberta Edmonton AB Canada
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36
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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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Affiliation(s)
- Jeff S Healey
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - William F McIntyre
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada
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Bouida W, Beltaief K, Msolli MA, Azaiez N, Ben Soltane H, Sekma A, Trabelsi I, Boubaker H, Grissa MH, Methemem M, Boukef R, Dridi Z, Belguith A, Nouira S. Low-dose Magnesium Sulfate Versus High Dose in the Early Management of Rapid Atrial Fibrillation: Randomized Controlled Double-blind Study (LOMAGHI Study). Acad Emerg Med 2019; 26:183-191. [PMID: 30025177 DOI: 10.1111/acem.13522] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 07/12/2018] [Accepted: 07/14/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We aim to determine the benefit of two different doses magnesium sulfate (MgSO4 ) compared to placebo in rate control of rapid atrial fibrillation (AF) managed in the emergency department (ED). METHODS We undertook a randomized, controlled, double-blind clinical trial in three university hospital EDs between August 2009 and December 2014. Patients > 18 years with rapid AF (>120 beats/min) were enrolled and randomized to 9 g of intravenous MgSO4 (high-dose group, n = 153), 4.5 g of intravenous MgSO4 (low-dose group, n = 148), or serum saline infusion (placebo group, n = 149), given in addition to atrioventricular (AV) nodal blocking agents. The primary outcome was the reduction of baseline ventricular rate (VR) to 90 beats/min or less or reduction of VR by 20% or greater from baseline (therapeutic response). Secondary outcome included resolution time (defined as the elapsed time from start of treatment to therapeutic response), sinus rhythm conversion rate, and adverse events within the first 24 hours. RESULTS At 4 hours, therapeutic response rate was higher in low- and high-MgSO4 groups compared to placebo group; the absolute differences were, respectively, 20.5% (risk ratio [RR] = 2.31, 95% confidence interval [CI] = 1.45-3.69) and +15.8% (RR = 1.89, 95% CI = 1.20-2.99). At 24 hours, compared to placebo group, therapeutic response difference was +14.1% (RR = 9.74, 95% CI = 2.87-17.05) with low-dose MgSO4 and +10.3% (RR = 3.22, 95% CI = 1.45-7.17) with high-dose MgSO4 . The lowest resolution time was observed in the low-dose MgSO4 group (5.2 ± 2 hours) compared to 6.1 ± 1.9 hours in the high-dose MgSO4 group and 8.4 ± 2.5 hours in the placebo group. Rhythm control rate at 24 hours was significantly higher in the low-dose MgSO4 group (22.9%) compared to the high-dose MgSO4 group (13.0%, p = 0.03) and the placebo group (10.7%). Adverse effects were minor and significantly more frequent with high-dose MgSO4 . CONCLUSIONS Intravenous MgSO4 appears to have a synergistic effect when combined with other AV nodal blockers resulting in improved rate control. Similar efficacy was observed with 4.5 and 9 g of MgSO4 but a dose of 9 g was associated with more side effects.
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Affiliation(s)
- Wahid Bouida
- Emergency Department Fattouma Bourguiba University Hospital Monastir
- Research Laboratory LR12SP18 University of Monastir Monastir
| | - Kaouthar Beltaief
- Emergency Department Fattouma Bourguiba University Hospital Monastir
- Research Laboratory LR12SP18 University of Monastir Monastir
| | - Mohamed Amine Msolli
- Emergency Department Fattouma Bourguiba University Hospital Monastir
- Research Laboratory LR12SP18 University of Monastir Monastir
| | | | - Houda Ben Soltane
- Research Laboratory LR12SP18 University of Monastir Monastir
- Emergency Department Farhat Hached University Hospital Sousse Tunisia
| | - Adel Sekma
- Emergency Department Fattouma Bourguiba University Hospital Monastir
- Research Laboratory LR12SP18 University of Monastir Monastir
| | - Imen Trabelsi
- Research Laboratory LR12SP18 University of Monastir Monastir
| | - Hamdi Boubaker
- Emergency Department Fattouma Bourguiba University Hospital Monastir
- Research Laboratory LR12SP18 University of Monastir Monastir
| | - Mohamed Habib Grissa
- Emergency Department Fattouma Bourguiba University Hospital Monastir
- Research Laboratory LR12SP18 University of Monastir Monastir
| | - Mehdi Methemem
- Emergency Department Farhat Hached University Hospital Sousse Tunisia
| | - Riadh Boukef
- Emergency Department Sahloul University Hospital Sousse
- Research Laboratory LR12SP18 University of Monastir Monastir
| | - Zohra Dridi
- Cardiology Department Fattouma Bourguiba University Hospital Monastir
| | - Asma Belguith
- Department of Preventive Medicine Fattouma Bourguiba University Hospital Monastir
| | - Semir Nouira
- Emergency Department Fattouma Bourguiba University Hospital Monastir
- Research Laboratory LR12SP18 University of Monastir Monastir
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Davarashvili I, Acha MR, Glikson M, Farkash R, Mazouz B, Butnaru A, Hasin T. Pulmonary Congestion Complicating Atrial Fibrillation Cardioversion. Am J Cardiol 2018; 122:1701-1706. [PMID: 30262403 DOI: 10.1016/j.amjcard.2018.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 08/05/2018] [Accepted: 08/09/2018] [Indexed: 11/26/2022]
Abstract
Acute pulmonary congestion (APC) may occur within hours after electrical cardioversion of atrial fibrillation (AF). There is scarce data about its incidence, risk factors, and the outcome. In the present study, data of consecutive patients admitted for first electrical cardioversion for AF between 2007 and 2016 were retrospectively reviewed. APC within the 48 hours following cardioversion was defined as dyspnea and at least one of the following: drop in saturation to <90%, administration of intravenous diuretic or an emergent chest X-ray with new pulmonary congestion. All-cause mortality was determined from the national registry. Total of 1,696 patients had first cardioversion for AF, of whom 66 (3.9%) had APC. In a multivariate logistic regression model independent predictors of APC included (OR [CI], p): older age (odds ratio [OR] 1.05, 95% confidence interval [CI] 1.02 to 1.08, p = 0.001), rapid ventricular response (OR 1.98, 95% CI 1.17 to 3.34, 0.010), previous heart failure (OR 3.53, 95% CI 2.09 to 5.97, p <0.001), Amiodarone loading (OR 2.38, 95% CI 1.18 to 4.79, p = 0.016) and diabetes mellitus (OR 1.77 95% CI 1.05 to 3.00, p = 0.033). There was no difference in cardioversion success rate (overall 94%). In-hospital mortality was 1.5% within the APC group and 0.5% without (p = 0.301). Patients with APC had higher rate of 6-month readmissions (28.8% vs 18.1% p <0.028). Within a median follow-up of 2.9 years, APC following cardioversion was an independent predictor of overall mortality (hazard ratio 1.73, 95% CI (1.17 to 2.56) p = 0.006). In conclusion, APC occurs in 3.9% of hospitalized patients following electrical AF cardioversion. Risk factors include increased age, diabetes mellitus, heart failure, Amiodarone loading and rapid ventricular response. APC following cardioversion is associated with increased rates of readmissions and mortality.
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Morgenstern J, Heitz C, Bond C, Milne WK. Hot Off the Press: A Novel Algorithm to Decrease Unnecessary Hospitalizations in Patients with Atrial Fibrillation. Acad Emerg Med 2018; 25:1284-1286. [PMID: 30003641 DOI: 10.1111/acem.13514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 07/09/2018] [Indexed: 11/29/2022]
Affiliation(s)
| | - Corey Heitz
- Virginia Tech Carilion School of Medicine, Roanoke, VA
| | - Chris Bond
- University of Calgary, Calgary, Alberta, Canada
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Atzema CL, Dorian P, Fang J, Tu JV, Lee DS, Chong AS, Austin PC. A clinical decision instrument to predict 30-day death and cardiovascular hospitalizations after an emergency department visit for atrial fibrillation: The Atrial Fibrillation in the Emergency Room, Part 2 (AFTER2) study. Am Heart J 2018; 203:85-92. [PMID: 30053692 DOI: 10.1016/j.ahj.2018.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 06/05/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND In previous work, we derived and validated a tool that predicts 30-day mortality in emergency department atrial fibrillation (AF) patients. The objective of this study was to derive and validate a tool that predicts a composite of 30-day mortality and return cardiovascular hospitalizations. METHODS This retrospective cohort study at 24 emergency departments in Ontario, Canada, included patients with a primary diagnosis of AF who were seen between April 2008 and March 2009. We assessed a composite outcome of 30-day mortality and subsequent hospitalizations for a cardiovascular reason, including stroke. RESULTS Of 3,510 patients, 2,343 were randomly selected for the derivation cohort, leaving 1,167 in the validation cohort. The composite outcome occurred in 227 (9.7%) and 125 (10.7%) patients in the derivation and validation cohorts, respectively. Eleven variables were independently associated with the outcome: older age, not taking anticoagulation, HAS-BLED score of ≥3, 3 laboratory results (positive troponin, supratherapeutic international normalized ratio, and elevated creatinine), emergency department administration of furosemide, and 4 patient comorbidities (heart failure, chronic obstructive lung disease, cancer, dementia). In the validation cohort, the observed 30-day outcomes in the 5 risk strata that were defined using the derivation cohort were 2.0%, 6.6%, 10.7%, 12.5%, and 20.0%. The c statistic was 0.73 and 0.69 in the derivation and validation cohort, respectively. CONCLUSIONS Using a population-based sample, we derived and validated a tool that predicts the risk of early death and rehospitalization for a cardiovascular reason in emergency department AF patients. The tool can offer information to managing physicians about the risk of death and rehospitalization for AF patients seen in the in emergency department, as well as identify patient groups for future targeted interventions aimed at preventing these outcomes.
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Affiliation(s)
- Clare L Atzema
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Division of Emergency Medicine, the Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation at the University of Toronto, Toronto, Ontario, Canada.
| | - Paul Dorian
- Division of Cardiology, the Department of Medicine, University of Toronto, Toronto, Ontario, Canada; St Michael's Hospital, Toronto, Ontario, Canada
| | - Jiming Fang
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Jack V Tu
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation at the University of Toronto, Toronto, Ontario, Canada; Division of Internal Medicine, the Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Douglas S Lee
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation at the University of Toronto, Toronto, Ontario, Canada; Division of Cardiology, the Department of Medicine, University of Toronto, Toronto, Ontario, Canada; University Health Network, Toronto, Ontario, Canada
| | - Alice S Chong
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Peter C Austin
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation at the University of Toronto, Toronto, Ontario, Canada
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Baugh CW, Clark CL, Wilson JW, Stiell IG, Kocheril AG, Luck KK, Myers TD, Pollack CV, Roumpf SK, Tomassoni GF, Williams JM, Patel BB, Wu F, Pines JM. Creation and Implementation of an Outpatient Pathway for Atrial Fibrillation in the Emergency Department Setting: Results of an Expert Panel. Acad Emerg Med 2018. [PMID: 29524340 DOI: 10.1111/acem.13410] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Atrial fibrillation and flutter (AF) is a common condition among emergency department (ED) patients in the United States. Traditionally, ED care for primary complaints related to AF focus on rate control, and patients are often admitted to an inpatient setting for further care. Inpatient care may include further telemetry monitoring and diagnostic testing, rhythm control, a search for identification of AF etiology, and stroke prophylaxis. However, many patients are eligible for safe and effective outpatient management pathways. They are widely used in Canada and other countries but less widely adopted in the United States. In this project, we convened an expert panel to create a practical framework for the process of creating, implementing, and maintaining an outpatient AF pathway for emergency physicians to assess and treat AF patients, safely reduce hospitalization rates, ensure appropriate stroke prophylaxis, and effectively transition patients to longitudinal outpatient treatment settings from the ED and/or observation unit. To support local pathway creation, the panel also reached agreement on a protocol development plan, a sample pathway, consensus recommendations for pathway components, sample pathway metrics, and a structured literature review framework using a modified Delphi technique by a technical expert panel of emergency medicine, cardiology, and other stakeholder groups.
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Affiliation(s)
| | - Carol L. Clark
- Department of Emergency Medicine Beaumont Health System Royal Oak MI
| | - Jason W. Wilson
- Department of Emergency Medicine Tampa General Hospital Tampa FL
| | - Ian G. Stiell
- Department of Emergency Medicine University of Ottawa Ottawa Hospital Research Institute Ottawa OntarioCanada
| | - Abraham G. Kocheril
- Department of Cardiology Presence Medical Group and University of Illinois Urbana IL
| | | | - Troy D. Myers
- Department of Emergency Medicine CarolinaEast Medical Center New Bern NC
| | - Charles V. Pollack
- Department of Emergency Medicine Thomas Jefferson University Philadelphia PA
| | - Steven K. Roumpf
- Department of Emergency Medicine Indiana University Health IndianapolisIN
| | | | | | - Brian B. Patel
- Department of Emergency Medicine Sturdy Memorial Hospital Attleboro MA
| | - Fred Wu
- Department of Emergency Medicine UCSF Fresno Fresno CA
| | - Jesse M. Pines
- Department of Emergency Medicine George Washington University School of Medicine and Health Sciences Washington DC
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Emergency medicine considerations in atrial fibrillation. Am J Emerg Med 2018; 36:1070-1078. [DOI: 10.1016/j.ajem.2018.01.066] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 01/22/2018] [Accepted: 01/23/2018] [Indexed: 12/29/2022] Open
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DeMeester S, Hess RA, Hubbard B, LeClerc K, Ferraro J, Albright JJ. Implementation of a Novel Algorithm to Decrease Unnecessary Hospitalizations in Patients Presenting to a Community Emergency Department With Atrial Fibrillation. Acad Emerg Med 2018; 25:641-649. [PMID: 29385655 DOI: 10.1111/acem.13383] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 01/08/2018] [Accepted: 01/15/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Atrial fibrillation (AFib) is the most common dysrhythmia in the United States. Patients seen in the emergency department (ED) in rapid AFib are often started on intravenous rate-controlling agents and admitted for several days. Although underlying and triggering illnesses must be addressed, AFib, intrinsically, is rarely life-threatening and can often be safely managed in an outpatient setting. At our academic community hospital, we implemented an algorithm to decrease hospital admissions for individuals presenting with a primary diagnosis of AFib. We focused on lenient oral rate control and discharge home. Our study evaluates outcomes after implementation of this algorithm. METHODS Study design is a retrospective cohort analysis pre- and postimplementation of the algorithm. The primary outcome was hospital admissions. Secondary outcomes were 3- and 30-day ED visits and any associated hospital admissions. These outcomes were compared before (March 2013-February 2014) and after (March 2015-February 2016) implementation. Chi-square tests and logistic regressions were run to test for significant changes in the three outcome variables. RESULTS A total of 1,108 individuals met inclusion criteria with 586 patients in the preimplementation group and 522 in the postimplementation group. Cohorts were broadly comparable in terms of demographics and health histories. Admissions for persons presenting with AFib after implementation decreased significantly (80.4% pre vs. 67.4% post, adjusted odds ratio [OR] = 3.4, p < 0.001). Despite this difference there was no change in ED return rates within 3 or 30 days (adjusted ORs = 0.93 and 0.89, p = 0.91 and 0.73, respectively). CONCLUSIONS Implementation of a novel algorithm to identify and treat low-risk patients with AFib can significantly decrease the rate of hospital admissions without increased ED returns. This simple algorithm could be adopted by other community hospitals and help lower costs.
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Affiliation(s)
- Susanne DeMeester
- Department of Emergency Medicine St. Joseph Mercy Hospital Ann Arbor MI
| | - Rebecca A. Hess
- Department of Emergency Medicine St. Joseph Mercy Hospital Ann Arbor MI
| | - Bradley Hubbard
- Department of Cardiology St. Joseph Mercy Hospital Ann Arbor MI
| | - Kara LeClerc
- Department of Emergency Medicine St. Joseph Mercy Hospital Ann Arbor MI
| | - Jane Ferraro
- Department of Emergency Medicine St. Joseph Mercy Hospital Ann Arbor MI
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Zhan Y, Joza J, Al Rawahi M, Barbosa RS, Samuel M, Bernier M, Huynh T, Thanassoulis G, Essebag V. Assessment and Management of the Left Atrial Appendage Thrombus in Patients With Nonvalvular Atrial Fibrillation. Can J Cardiol 2018; 34:252-261. [DOI: 10.1016/j.cjca.2017.12.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 12/04/2017] [Accepted: 12/11/2017] [Indexed: 01/14/2023] Open
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De Leon E, Duan L, Rippenberger E, Sharp AL. Impact of Standardizing Management of Atrial Fibrillation with Rapid Heart Rate in the Emergency Department. Perm J 2018; 22:17-049. [PMID: 29401054 DOI: 10.7812/tpp/17-049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
CONTEXT There is substantial variation in the emergency treatment of atrial fibrillation with tachycardia. A standardized treatment approach at an academic center decreased admissions without adverse outcomes, but this approach has not been evaluated in a community Emergency Department (ED). OBJECTIVE To evaluate the implementation of a standardized treatment guideline for patients with atrial fibrillation and a rapid heart rate in a community ED. DESIGN An observational pre-/postimplementation (August 2013 to July 2014 and August 2014 to July 2015, respectively) study at a community ED. The standardized treatment guideline encouraged early oral treatment with rate control medication, outpatient echocardiogram, and early follow-up. A multiple logistic regression model adjusting for patient characteristics was generated to investigate the association between the intervention and ED discharge rate. MAIN OUTCOME MEASURES The primary measure was ED discharge. Secondary measures included stroke or death, ED return visit, hospital readmission, length of stay, and use of oral rate control medications. RESULTS A total of 199 (104 pre/95 post) ED encounters were evaluated. The ED discharge rate increased 14% after intervention (57.7% to 71.6%, p = 0.04), and use of rate control medications increased by 19.4% (p < 0.01). Adjusted multivariate results showed a nearly 2-fold likelihood of ED discharge after guideline implementation (odds ratio = 1.97, 95%confidence interval = 1.07-3.63). Length of stay, return visits, and hospital readmissionswere similar. CONCLUSION A standardized approach to ED patients with atrial fibrillation and tachycardia is associated with a decrease in hospital admissions without adversely affecting patient safety.
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Affiliation(s)
- Ernesto De Leon
- Emergency Physician at the Panorama City Medical Center in CA.
| | - Lewei Duan
- Biostatistician in the Southern California Permanente Medical Group Department of Research and Evaluation in Pasadena.
| | - Ellen Rippenberger
- Clinical Research Associate in the Division of Biomarkers, Early Detection and Prevention at the City of Hope in Duarte, CA.
| | - Adam L Sharp
- Research Scientist in the Southern California Permanente Medical Group Department of Research and Evaluation in Pasadena.
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Rhythm and rate control of atrial fibrillation in the emergency department – A large community-based observational study. CAN J EMERG MED 2017; 20:834-840. [DOI: 10.1017/cem.2017.421] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjectiveAtrial fibrillation (AF) is the most common arrhythmia presentation to the emergency department (ED) and frequently results in admission to the hospital. Although rarely life-threatening and not usually an emergent condition, AF places a large burden on our health-care system. The objective of this study was to describe the practices of ED physicians in the management of AF in a large urban Canadian city.MethodsFrom January 1, 2010 to December 31, 2010, patients with a primary diagnosis of AF were identified across 10 EDs in Toronto, Canada (N=2,609). Fifty patients were selected at random from each hospital for a detailed chart review (n=500).ResultsTwo hundred thirty-two patients (46%) received rate control, and 129 (26%) received rhythm control with the remainder (28%) receiving neither therapy. Sixty-seven percent of patients were discharged home. Most patients (79%) were symptomatic on arrival; however, only a minority of these (31%) received rhythm control. Factors that were associated with rhythm control included younger age, duration of palpitations ≤ 48 hours, a lower CHADS2 score, and the absence of left ventricular dysfunction.ConclusionOur data suggest a wide range of practice amongst ED physicians treating patients presenting to the ED with a primary diagnosis of AF. A randomized trial is needed to better understand the optimal management strategy in this patient population and setting.
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Atzema CL, Austin PC. Rate Control With Beta-blockers Versus Calcium Channel Blockers in the Emergency Setting: Predictors of Medication Class Choice and Associated Hospitalization. Acad Emerg Med 2017; 24:1334-1348. [PMID: 28853232 DOI: 10.1111/acem.13303] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 07/18/2017] [Accepted: 08/15/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Rate control is an important component of the management of patients with atrial fibrillation (AF). Previous studies of emergency department (ED) rate control have been limited by relatively small sample sizes. We examined the use of beta-blockers (BBs) versus nondihydropyridine calcium channel blockers (CCBs) in ED patients from 24 sites and the associated hospital admission rates. METHODS In this preplanned substudy, we examined chart data on AF patients who visited one of 24 hospital EDs in Ontario, Canada, between April 2008 and March 2009. We describe the proportion of patients who received either a BB or a CCB, had a heart rate < 110 beats/min 2 hours later, and had any complications. We used hierarchical logistic regression modeling to determine the predictors of BB versus CCB use and to assess the between-hospital variation in use of BBs versus CCBs. Solely in patients who had no rhythm control attempts, we examined the difference in the probability of hospital admission after propensity score matching patients by medication class. RESULTS Of the 1,639 patients who received either a BB (n = 429) or a CCB (n = 1,210), 70.9% of the patients who received a BB had successful rate control versus 66.1% for a CCB. Complications were rare (2.4%), and the large majority were hypotension (2.0%). In adjusted analyses, predictors of receiving a BB (compared to a CCB) included already being on a BB, being sent in from a doctor's office, or being seen at a teaching hospital. In contrast, patients with evidence of heart failure, prior use of a CCB, a higher presenting heart rate, or a successful pharmacologic cardioversion (vs. no attempt) or who were seen at the highest AF volume EDs were significantly less likely to receive a BB, compared to a CCB. Systematic between-hospital differences accounted for 8% of the variation in BB versus CCB use. Hospital characteristics accounted for the large majority of that variation: after accounting for patient characteristics the between-hospital variation decreased by a relative 2.8%. By further adjusting for hospital characteristics, it decreased by a relative 74.7%. Among propensity score-matched patients with no rhythm control attempts, more CCB patients were admitted (51.6%) compared to BB patients (40.0%; difference of 11.6%; 95% confidence interval = 7.9%-16.2%). CONCLUSIONS In this study of 24 EDs, CCBs were used more frequently for rate control than BBs, and complications were rare and easily managed using both agents. Variation between hospitals in BB versus CCB use was predominantly due to hospital characteristics such as teaching status and AF volumes, rather than different case mix. Among patients who did not receive attempts at rhythm control, use of a BB for rate control was associated with a lower rate of hospitalization.
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Affiliation(s)
- Clare L. Atzema
- Department of Trauma, Emergency and Critical Care; Sunnybrook Health Sciences Centre; Toronto Ontario Canada
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
| | - Peter C. Austin
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
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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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