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Kłosiewicz T, Cholerzyńska H, Zasada WA, Shadi A, Olszewski J, Konieczka P, Podlewski R, Puślecki M. Impact of Various Atrial Fibrillation Treatment Strategies on Length of Stay in the Emergency Department and Early Complications-3 Years of a Single-Center Experience. J Clin Med 2023; 13:190. [PMID: 38202197 PMCID: PMC10779744 DOI: 10.3390/jcm13010190] [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: 10/27/2023] [Revised: 11/29/2023] [Accepted: 12/26/2023] [Indexed: 01/12/2024] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia presenting in emergency departments (EDs), vastly increasing mainly due to society's lifestyles leading to numerous comorbidities. Its management depends on many factors and is still not unified. Aims: The aim of this study was to compare different AF management strategies in the ED and to evaluate their influence on the length of stay (LOS) in the ED and their safety. We analyzed medical records over 3 years of data collection, including age, primary AF diagnosis, an attempt to restore sinus rhythm, complications, and length of stay. Patients were divided into three groups according to the treatment method received: only pharmacological cardioversion (MED), only electrical cardioversion (EC), and patients who received medications followed by electrical cardioversion (COMB). We included 599 individuals in the analysis with a median age of 71. The restoration of sinus rhythm and LOS were as follows: MED: 64.95%, 173 min; COMB: 87.91%, 295 min; SH: 92.40%, 180 min. The difference between the MED and EC strategies, as well as MED and COMB, was statistically significant (p < 0.001 in both). The total number of complications was 16, with a rate of 32.67%. The majority of them followed a drug administration, and the most common complication was bradycardia. Electrical cardioversion is a safe and effective treatment strategy in stable patients with AF in the ED. It is associated with a shortened LOS. Medication administration preceded the majority of complications.
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Affiliation(s)
- Tomasz Kłosiewicz
- Department of Emergency Medicine, Poznan University of Medical Sciences, 7 Rokietnicka Street, 60-608 Poznań, Poland; (H.C.); (W.A.Z.); (P.K.); (R.P.); (M.P.)
| | - Hanna Cholerzyńska
- Department of Emergency Medicine, Poznan University of Medical Sciences, 7 Rokietnicka Street, 60-608 Poznań, Poland; (H.C.); (W.A.Z.); (P.K.); (R.P.); (M.P.)
| | - Wiktoria Antonina Zasada
- Department of Emergency Medicine, Poznan University of Medical Sciences, 7 Rokietnicka Street, 60-608 Poznań, Poland; (H.C.); (W.A.Z.); (P.K.); (R.P.); (M.P.)
| | - Amira Shadi
- College of Emergency Physicians in Poland, 5 Truflowa Street, 62-070 Dopiewiec, Poland; (A.S.); (J.O.)
| | - Jakub Olszewski
- College of Emergency Physicians in Poland, 5 Truflowa Street, 62-070 Dopiewiec, Poland; (A.S.); (J.O.)
| | - Patryk Konieczka
- Department of Emergency Medicine, Poznan University of Medical Sciences, 7 Rokietnicka Street, 60-608 Poznań, Poland; (H.C.); (W.A.Z.); (P.K.); (R.P.); (M.P.)
| | - Roland Podlewski
- Department of Emergency Medicine, Poznan University of Medical Sciences, 7 Rokietnicka Street, 60-608 Poznań, Poland; (H.C.); (W.A.Z.); (P.K.); (R.P.); (M.P.)
| | - Mateusz Puślecki
- Department of Emergency Medicine, Poznan University of Medical Sciences, 7 Rokietnicka Street, 60-608 Poznań, Poland; (H.C.); (W.A.Z.); (P.K.); (R.P.); (M.P.)
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Halvorsen S, Mehilli J, Cassese S, Hall TS, Abdelhamid M, Barbato E, De Hert S, de Laval I, Geisler T, Hinterbuchner L, Ibanez B, Lenarczyk R, Mansmann UR, McGreavy P, Mueller C, Muneretto C, Niessner A, Potpara TS, Ristić A, Sade LE, Schirmer H, Schüpke S, Sillesen H, Skulstad H, Torracca L, Tutarel O, Van Der Meer P, Wojakowski W, Zacharowski K. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J 2022; 43:3826-3924. [PMID: 36017553 DOI: 10.1093/eurheartj/ehac270] [Citation(s) in RCA: 247] [Impact Index Per Article: 123.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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Can I Send This Patient With Atrial Fibrillation Home From the Emergency Department? J Emerg Med 2022; 63:600-612. [DOI: 10.1016/j.jemermed.2022.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/10/2022] [Accepted: 07/10/2022] [Indexed: 11/06/2022]
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Kanawati J, Kumar S. Atrial Fibrillation Clinics: The Way of the Future. Heart Lung Circ 2022; 31:155-157. [PMID: 35027117 DOI: 10.1016/j.hlc.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Juliana Kanawati
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia. https://twitter.com/SaurabhKumarEP
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Implementation of a Procainamide-Based Cardioversion Strategy for the Management of Recent-Onset Atrial Fibrillation. Adv Emerg Nurs J 2021; 43:186-193. [PMID: 34397493 DOI: 10.1097/tme.0000000000000358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Atrial fibrillation/flutter (AF) remains the most common rhythm disturbance in adult patients presenting to emergency departments (EDs). Although pharmacologic cardioversion has been established as safe and effective in recent-onset AF, its use in U.S. EDs is uncommon. The purpose of this study was to assess the safety and efficacy of intravenous (IV) procainamide for pharmacologic cardioversion in patients presenting to the ED with AF of <48-hr duration. Patients presenting to the ED with recent-onset AF (<48 hr) undergoing a cardioversion strategy with IV procainamide from 2017 to 2019 were reviewed. Clinical outcomes assessed included rates of cardioversion, hospital admission, stroke, and return ED visits for arrhythmia or serious adverse events. A total of 64 patients received procainamide therapy-60.9% achieved cardioversion and 35.9% were admitted to the hospital. The mean dose was 1062.4 mg (12.1 mg/kg). No patients returned to the ED secondary to stroke and 9.4% experienced complications attributed to procainamide, the most common being hypotension. Within 30 days of therapy, 20.3% of patients returned to the ED secondary to arrhythmia recurrence. Patients experiencing cardioversion with procainamide were less likely to be admitted to the hospital (25.6% vs. 52.0%; p = 0.04) or receive a rate control agent (17.9% vs. 64.0%; p = 0.001). There was no significant difference in the rate of 30-day return between those who experienced pharmacologic cardioversion and those who did not (p = 0.220). The implementation of a procainamide-based acute cardioversion strategy for patients presenting to the ED with recent-onset AF resulted in a 60% cardioversion rate, which was associated with a significantly higher rate of discharge from the ED. Transient hypotension was the most common adverse event. Further investigation into ED-based protocols for management of recent-onset AF is necessary to better understand their safety and efficacy.
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Wong BM, Perry JJ, Cheng W, Zheng B, Guo K, Taljaard M, Skanes AC, Stiell IG. Thromboembolic events following cardioversion of acute atrial fibrillation and flutter: a systematic review and meta-analysis. CAN J EMERG MED 2021; 23:500-511. [PMID: 33715143 DOI: 10.1007/s43678-021-00103-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 02/09/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Recent studies have presented concerning data on the safety of cardioversion for acute atrial fibrillation and flutter. We conducted this meta-analysis to evaluate the effect of oral anticoagulation use on thromboembolic events post-cardioversion of low-risk acute atrial fibrillation and flutter patients of < 48 h in duration. METHODS We searched MEDLINE, Embase, and Cochrane from inception through February 6, 2020 for studies reporting thromboembolic events post-cardioversion of acute atrial fibrillation and flutter. Main outcome was thromboembolic events within 30 days post-cardioversion. Primary analysis compared thromboembolic events based on oral anticoagulation use versus no oral anticoagulation use. Secondary analysis was based on baseline thromboembolic risk. We performed meta-analyses where 2 or more studies were available, by applying the DerSimonian-Laird random-effects model. Risk of bias was assessed with the Quality in Prognostic Studies tool. RESULTS Of 717 titles screened, 20 studies met inclusion criteria. Primary analysis of seven studies with low risk of bias demonstrated insufficient evidence regarding the risk of thromboembolic events associated with oral anticoagulation use (RR = 0.82 where RR < 1 suggests decreased risk with oral anticoagulation use; 95% CI 0.27 to 2.47; I2 = 0%). Secondary analysis of 13 studies revealed increased risk of thromboembolic events with high baseline thromboembolic risk (RR = 2.25 where RR > 1 indicates increased risk with higher CHADS2 or CHA2DS2-VASc scores; 95% CI 1.25 to 4.04; I2 = 0%). CONCLUSION Primary analysis revealed insufficient evidence regarding the effect of oral anticoagulation use on thromboembolic events post-cardioversion of low-risk acute atrial fibrillation and flutter, though the event rate is low in contemporary practice. Our findings can better inform patient-centered decision-making when considering 4-week oral anticoagulation use for acute atrial fibrillation and flutter patients.
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Affiliation(s)
- Brenton M Wong
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Wei Cheng
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Bo Zheng
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Kevin Guo
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Allan C Skanes
- Division of Cardiology, Western University, London, ON, Canada
| | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
- Clinical Epidemiology Unit, The Ottawa Hospital, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada.
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Al-Busaidi IS, Clare GC, Joyce LR, Pearson S, Lainchbury J, Than M, Troughton RW. Presentation, Treatment and Long-Term Outcomes of a Multidisciplinary Acute Atrial Fibrillation Pathway: A 12-Month Follow-Up Study. Heart Lung Circ 2021; 31:216-223. [PMID: 34210615 DOI: 10.1016/j.hlc.2021.05.102] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/01/2021] [Accepted: 05/16/2021] [Indexed: 11/17/2022]
Abstract
AIM Atrial fibrillation/flutter (AF/AFL) is associated with high rates of emergency department (ED) visits and acute hospitalisation. A recently established multidisciplinary acute AF treatment pathway seeks to avoid hospital admissions by early discharge of haemodynamically stable, low risk patients from the ED with next-working-day return to a ward-based AF clinic for further assessment. We conducted a preliminary analysis of the clinical outcomes of this pathway. METHODS We retrospectively reviewed clinical records of all patients assessed at the AF clinic at Christchurch Hospital over a 12-month period. Data related to presentation, patient characteristics, treatment, and 12-month outcomes were analysed. RESULTS A total of 143 patients (median age 65, interquartile range: 57-74 years, 59% male, 87% European) were assessed. Of these, 87 (60.8%) presented with their first episode of AF/AFL. Spontaneous cardioversion occurred in 41% at ED discharge, and this increased to 73% at AF clinic review. Electrical cardioversion was subsequently performed in 16 patients (11.2%), and 16 (11.2%) ultimately required hospital admission (eight to facilitate electrical cardioversion). At a median of 1 day, 83.9% were discharged from the AF clinic in sinus rhythm. During 12-month follow-up, there were 25 AF-related hospitalisations (20 patients, 14%) and one patient underwent electrical cardioversion; additionally, one patient had had a stroke and eight had bleeding complications giving a combined outcome rate of 6.3%. CONCLUSION Utilising a rate-control strategy with ED discharge and early return to a dedicated AF clinic can safely prevent the majority of hospitalisations, avert unnecessary procedures, and facilitate longitudinal care.
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Affiliation(s)
- Ibrahim S Al-Busaidi
- Department of Medicine, University of Otago, Christchurch, New Zealand; Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand.
| | - Geoffrey C Clare
- Department of Medicine, University of Otago, Christchurch, New Zealand; Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Laura R Joyce
- Department of Surgery, University of Otago, Christchurch, New Zealand; Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - Scott Pearson
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - John Lainchbury
- Department of Medicine, University of Otago, Christchurch, New Zealand; Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Martin Than
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - Richard W Troughton
- Department of Medicine, University of Otago, Christchurch, New Zealand; Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
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8
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, Meir ML, Lane DA, Lebeau JP, Lettino M, Lip GY, Pinto FJ, Neil Thomas G, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. Guía ESC 2020 sobre el diagnóstico y tratamiento de la fibrilación auricular, desarrollada en colaboración de la European Association of Cardio-Thoracic Surgery (EACTS). Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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9
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021; 42:373-498. [PMID: 32860505 DOI: 10.1093/eurheartj/ehaa612] [Citation(s) in RCA: 5210] [Impact Index Per Article: 1736.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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10
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Pluymaekers NA, Hermans AN, Linz DK, Dudink EA, Luermans JG, Weijs B, Vernooy K, Crijns HJ. Frequency and Determinants of Spontaneous Conversion to Sinus Rhythm in Patients Presenting to the Emergency Department with Recent-onset Atrial Fibrillation: A Systematic Review. Arrhythm Electrophysiol Rev 2021; 9:195-201. [PMID: 33437487 PMCID: PMC7788393 DOI: 10.15420/aer.2020.34] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The exact frequency and clinical determinants of spontaneous conversion (SCV) in patients with symptomatic recent-onset AF are unclear. The aim of this systematic review is to provide an overview of the frequency and determinants of SCV of AF in patients presenting at the emergency department. A comprehensive literature search for studies about SCV in patients presenting to the emergency department with AF resulted in 25 articles - 12 randomised controlled trials and 13 observational studies. SCV rates range between 9-83% and determinants of SCV also varied between studies. The most important determinants of SCV included short duration of AF (<24 or <48 hours), low number of episodes, normal atrial dimensions and absence of previous heart disease. The large variation in SCV rate and determinants of SCV was related to differences in duration of the observation period, inclusion and exclusion criteria and in variables used in the prediction models.
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Affiliation(s)
- Nikki Aha Pluymaekers
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Astrid Nl Hermans
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Dominik K Linz
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands.,Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Elton Amp Dudink
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Justin Glm Luermans
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands.,Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Bob Weijs
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands.,Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Harry Jgm Crijns
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
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Abstract
Atrial fibrillation (AF) is the most common tachyarrhythmia managed in the emergency department (ED). Visits to the ED for a presentation of AF have been increasing in recent years, with an admission rate that exceeds 60% in the United States and contributes substantially to health care costs. Recent-onset AF-defined as symptom onset less than 48 hr-is a common ED presentation for which rate control or acute electrical or pharmacological cardioversion may be appropriate treatment modalities depending on patient-specific circumstances. The focus of this review is to discuss the current recommendations regarding the management of recent-onset nonvalvular AF in the ED, discuss medication administration considerations, and identify implementation strategies in the ED to optimize throughput and reduce hospital admissions.
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12
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Decision aid for early identification of acute underlying illness in emergency department patients with atrial fibrillation or flutter. CAN J EMERG MED 2020; 22:301-308. [PMID: 31856926 DOI: 10.1017/cem.2019.454] [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] [Indexed: 11/06/2022]
Abstract
BACKGROUND Emergency department (ED) patients with atrial fibrillation or flutter (AFF) with underlying occult condition such as sepsis or heart failure, and who are managed with rate or rhythm control, have poor prognoses. Such conditions may not be easy to identify early in the ED evaluation when critical treatment decisions are made. We sought to develop a simple decision aid to quickly identify undifferentiated ED AFF patients who are at high risk of acute underlying illness. METHODS We collected consecutive ED patients with electrocardiogram-proven AFF over a 1-year period and performed a chart review to ascertain demographics, comorbidities, and investigations. The primary outcome was having an acute underlying illness according to prespecified criteria. We used logistic regression to identify factors associated with the primary outcome, and developed criteria to identify those with an underlying illness at presentation. RESULTS Of 1,083 consecutive undifferentiated ED AFF patients, 400 (36.9%) had an acute underlying illness; they were older with more comorbidities. Modeling demonstrated that three predictors (ambulance arrival; chief complaint of chest pain, dyspnea, or weakness; CHA2DS2-VASc score greater than 2) identified 93% of patients with acute underlying illness (95% confidence interval [CI], 91-96%) with 54% (95% CI, 50-58%) specificity. The decision aid missed 28 patients; (7.0%) simple blood tests and chest radiography identified all within an hour of presentation. CONCLUSIONS In ED patients with undifferentiated AFF, this simple predictive model rapidly differentiates patients at risk of acute underlying illness, who will likely merit investigations before AFF-specific therapy.
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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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Active management of atrial fibrillation or flutter in emergency department patients with renal impairment is associated with a higher risk of adverse events and treatment failure. CAN J EMERG MED 2019; 21:352-360. [DOI: 10.1017/cem.2018.475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ABSTRACTObjectiveAtrial fibrillation or flutter (AFF) patients with renal impairment have poor long-term prognosis, but their emergency department (ED) management has not been described. We investigated the association of renal impairment upon outcomes after rate or rhythm control (RRC) including ED-based adverse events (AE) and treatment failure.MethodsThis cohort study used an electrocardiogram database from two urban centres to identify consecutive AFF patients and reviewed charts to obtain comorbidities, ED management, including RRC, prespecified AE, and treatment failure. Patients were dichotomized into a normal estimated glomerular filtration rate (eGFR) > 60 mL/min/1.73 m2) or impaired renal function (“low eGFR”). Primary and secondary outcomes were prespecified AEs and treatment failure, respectively. We calculated 1) adjusted excess AE risk for patients with decreased renal function receiving RRC; and 2) adjusted odds ratio of RRC treatment failure.ResultsOf 1,112 consecutive ED AFF patients, 412 (37.0%) had a low eGFR. Crude AE rates for RRC were 27/238 (11.3%) for patients with normal renal function and 26/103 (25.2%) for patients with low eGFR. For patients with low eGFR receiving RRC, adjusted excess AE risk was 13.7%. (95% CI 1.7 to 25.1%). For patients with low eGFR, adjusted odds ratio for RRC failure was 3.07. (95% CI 1.74 to 5.43)ConclusionsIn this cohort of ED AFF patients receiving RRC, those with low eGFR had significantly increased adjusted excess risk of AE compared with patients with normal renal function. Odds of treatment failure were also significantly increased.
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Vandermolen JL, Sadaf MI, Gehi AK. Management and Disposition of Atrial Fibrillation in the Emergency Department: A Systematic Review. J Atr Fibrillation 2018; 11:1810. [PMID: 30455832 DOI: 10.4022/jafib.1810] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 03/19/2018] [Accepted: 05/26/2018] [Indexed: 12/18/2022]
Abstract
Introduction Management of atrial fibrillation (AF) and atrial flutter (AFL) in the emergency department (ED) varies greatly, and there are currently no United States guidelines to guide management with regard to patient disposition after ED treatment. The aim of this systematic review was to evaluate the literature for decision aids to guide disposition of patients with AF/AFLin the ED, and assess potential outcomes associated with different management strategies in the ED. Methods and Results A systematic review was done using PubMed (MEDLINE), Cochrane Central Register of Controlled Trials (CENTRAL), and EMBASE, combining the search terms "Atrial Fibrillation", "Atrial Flutter", "Emergency Medicine", "Emergency Service", and "Emergency Treatment". After removal of duplicates, 754 articles were identified. After initial screening of titles and abstracts, 69full text articles were carefully reviewed and 34 articles were ultimately included in the study based on inclusion and exclusion criteria. The articles were grouped into four main categories: decision aids and outcome predictors, electrical cardioversion-based protocols, antiarrhythmic-based protocols, and general management protocols. Conclusion This systematic review is the first study to our knowledge to evaluate the optimal management of symptomatic AF/AFLin the ED with a direct impact on ED disposition. There are several viable management strategies that can result in safe discharge from the ED in the right patient population, and decision aids can be utilized to guide selection of appropriate patients for discharge.
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Affiliation(s)
- Justin L Vandermolen
- Division of Cardiology, Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Murrium I Sadaf
- Division of Cardiology, Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Anil K Gehi
- Division of Cardiology, Department of Medicine, University of North Carolina, Chapel Hill, NC
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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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Tampieri A, Cipriano V, Mucci F, Rusconi AM, Lenzi T, Cenni P. Safety of cardioversion in atrial fibrillation lasting less than 48 h without post-procedural anticoagulation in patients at low cardioembolic risk. Intern Emerg Med 2018; 13:87-93. [PMID: 28025766 DOI: 10.1007/s11739-016-1589-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 12/01/2016] [Indexed: 10/20/2022]
Abstract
Currently, there is no unified consensus on short-term anticoagulation after cardioversion of atrial fibrillation lasting less than 48 h in low-cardioembolic-risk patients. The aim of this study is to evaluate the rate of transient ischemic attacks, stroke and death in this subset of patients after cardioversion without post-procedural anticoagulation. In a prospective observational study, patients with recent-onset AF undergoing cardioversion attempts in the Emergency Department were evaluated over the past 3 years. Inclusion criteria were conversion to sinus rhythm, low thromboembolic risk defined by a CHA2DS2VASc score of 0-1 points for males (0-2 points for females aged over 65 years), and hospital discharge without anticoagulant treatment. Patients with severe valvular heart disease, underlying systemic causes of AF, and those discharged with anticoagulant therapy were excluded. The main outcomes measured were TIA, stroke and death at thirty days' follow-up after discharge. During the study period, 218 successful cardioversions, obtained both electrically and pharmacologically, were performed on 157 patients. One hundred and eleven patients were males (71%), the mean age was 55.2 years (±standard deviation 10.7), 99 patients (63%) reported a CHA2DS2VASc score of 0, and the remaining 58 (37%) had a risk profile of 1 point. Of these, latter 8 were females (5%) older than 65 years (risk score 2 points). At the thirty days outcome, none of the 150 enrolled patients who completed a follow-up visit has reported TIA or stroke, nor died, in the overall 211 successful cardioversions evaluated. In our study, the rate of thromboembolic events after cardioversion of recent-onset AF of less than 48 h duration, in patients with a 0-1 CHA2DS2VASc risk profile (females 0-2), appeared to be extremely low even in absence of post-procedural anticoagulation. These findings seem to confirm data from previous studies, and suggest that routine post-procedural short-term anticoagulation may be considered as an overtreatment in this very low-risk subset of patients.
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Affiliation(s)
- Andrea Tampieri
- Emergency Department, S.Maria della Scaletta Hospital, via Montericco 4, Imola, 40026, Bologna, Italy.
| | - Valentina Cipriano
- Emergency Department, S.Maria della Scaletta Hospital, via Montericco 4, Imola, 40026, Bologna, Italy
| | - Fabrizio Mucci
- Emergency Department, S.Maria della Scaletta Hospital, via Montericco 4, Imola, 40026, Bologna, Italy
| | | | - Tiziano Lenzi
- Emergency Department, S.Maria della Scaletta Hospital, via Montericco 4, Imola, 40026, Bologna, Italy
| | - Patrizia Cenni
- Emergency Department, S.Maria della Scaletta Hospital, via Montericco 4, Imola, 40026, Bologna, Italy
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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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Cardiovascular Conditions in the Observation Unit: Beyond Chest Pain. Emerg Med Clin North Am 2017; 35:549-569. [PMID: 28711124 DOI: 10.1016/j.emc.2017.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The first emergency department observation units (EDOUs) focused on chest pain and potential acute coronary syndromes. However, most EDOUs now cover multiple other conditions that lend themselves to protocolized, aggressive diagnostic and therapeutic regimens. In this article, the authors discuss the management of 4 cardiovascular conditions that have been successfully deployed in EDOUs around the country.
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Jaakkola S, Lip GY, Biancari F, Nuotio I, Hartikainen JE, Ylitalo A, Airaksinen KJ. Predicting Unsuccessful Electrical Cardioversion for Acute Atrial Fibrillation (from the AF-CVS Score). Am J Cardiol 2017; 119:749-752. [PMID: 28017305 DOI: 10.1016/j.amjcard.2016.11.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 11/08/2016] [Accepted: 11/08/2016] [Indexed: 11/25/2022]
Abstract
Electrical cardioversion (ECV) is the standard treatment for acute atrial fibrillation (AF), but identification of patients with increased risk of ECV failure or early AF recurrence is of importance for rational clinical decision-making. The objective of this study was to derive and validate a clinical risk stratification tool for identifying patients at high risk for unsuccessful outcome after ECV for acute AF. Data on 2,868 patients undergoing 5,713 ECVs of acute AF in 3 Finnish hospitals from 2003 through 2010 (the FinCV study data) were included in the analysis. Patients from western (n = 3,716 cardioversions) and eastern (n = 1,997 cardioversions) hospital regions were used as derivation and validation datasets. The composite of cardioversion failure and recurrence of AF within 30 days after ECV was recorded. A clinical scoring system was created using logistic regression analyses with a repeated-measures model in the derivation data set. A multivariate analysis for prediction of the composite end point resulted in identification of 5 clinical variables for increased risk: Age (odds ratio [OR] 1.31, confidence interval [CI] 1.13 to 1.52), not the First AF (OR 1.55, CI 1.19 to 2.02), Cardiac failure (OR 1.52, CI 1.08 to 2.13), Vascular disease (OR 1.38, CI 1.11 to 1.71), and Short interval from previous AF episode (within 1 month before ECV, OR 2.31, CI 1.83 to 2.91) [hence, the acronym, AF-CVS]. The c-index for the AF-CVS score was 0.67 (95% CI 0.65 to 0.69) with Hosmer-Lemeshow p value 0.84. With high (>5) scores (i.e., 12% to 16% of the patients), the rate of composite end point was ∼40% in both cohorts, and among low-risk patients (score <3), the composite end point rate was ∼10%. In conclusion, the risk of ECV failure and early recurrence of AF can be predicted with simple patient and disease characteristics.
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Predictors and clinical outcomes of inpatient versus ambulatory management after an emergency department visit for atrial fibrillation: A population-based study. Am Heart J 2016; 173:161-9. [PMID: 26920609 DOI: 10.1016/j.ahj.2015.10.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 10/30/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND There is substantial variation in the management of atrial fibrillation (AF) in the emergency department (ED), particularly whether these patients are admitted to hospital. We sought to identify factors that predict admission and to examine the relationship between AF admission and outcomes. METHODS We performed a retrospective cohort analysis of patients ≥20 years of age who had an index ED visit with a primary diagnosis of AF from between April 1, 2005, and March 31, 2010, in Ontario, Canada. We excluded patients who died during the index ED visit or hospitalization. A hierarchical logistic regression model was used to determine predictors of hospital admission during the index ED visit. A propensity-matched analysis was used to test for associations between hospital admission and 1-year outcomes. RESULTS The cohort consisted of 33,699 patients, of whom 16,270 (48.3%) were admitted to hospital. Substantial variation was seen across the 154 hospitals, with admission rates ranging from 3.0% to 91.0%. Admitted patients had higher rates of comorbidities compared to discharged patients. Mortality rates at 1 year were significantly higher in matched admitted versus discharged patients (hazard ratio 1.45, 95% CI 1.33-1.57, P < .001), as were all-cause hospitalizations (hazard ratio 1.18, 95% CI 1.13-1.22, P < .001). CONCLUSIONS Wide practice variation was observed between hospitals in terms of the proportion of patients admitted. Our data suggest that selected patients when discharged have similar or improved outcomes compared to those who are initially admitted. Future research is needed to better standardize admission/discharge decisions for AF patients in the ED.
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Ballard DW, Reed ME, Singh N, Rauchwerger AS, Hamity CA, Warton EM, Chettipally UK, Mark DG, Vinson DR. Emergency Department Management of Atrial Fibrillation and Flutter and Patient Quality of Life at One Month Postvisit. Ann Emerg Med 2015; 66:646-654.e2. [DOI: 10.1016/j.annemergmed.2015.04.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Revised: 03/14/2015] [Accepted: 04/06/2015] [Indexed: 11/29/2022]
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Scheuermeyer FX, Mackay M, Christenson J, Grafstein E, Pourvali R, Heslop C, MacPhee J, Ward J, Heilbron B, McGrath L, Humphries K. There Are Sex Differences in the Demographics and Risk Profiles of Emergency Department (ED) Patients With Atrial Fibrillation and Flutter, but no Apparent Differences in ED Management or Outcomes. Acad Emerg Med 2015; 22:1067-75. [PMID: 26291513 DOI: 10.1111/acem.12750] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Revised: 04/19/2015] [Accepted: 04/27/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVES In non-emergency department (ED) settings, women with atrial fibrillation and flutter (AFF) have different presentations, treatments, and outcomes than men: they are older, less likely to be treated with rhythm control strategies or appropriate anticoagulation, and more likely to have strokes. This has not been investigated in ED patients. METHODS Records from consecutive ED patients from January 1 to December 31, 2009, with electrocardiogram-proven AFF at two urban hospitals were collected. Review of administrative and clinical data identified patient demographics, clinical characteristics, comorbidities, and ED treatments. The regional ED database was queried to determine 30-day and 1-year follow-up visits, and the provincial vital statistics database was referenced to obtain 30-day and 1-year mortality; all outcomes were stratified by sex. The primary outcome, which reflected overall appropriateness of ED care, was the proportion of patients who were discharged home at their index ED visits, who then had unscheduled 30-day ED revisits. Secondary outcomes included the proportion of eligible patients who underwent acute rhythm control strategies and the proportion of high-risk patients who had previously inadequately anticoagulation strategies corrected by the emergency physician. Additional outcomes included the ED length of stay (LOS) and 30-day and 1-year rates of stroke and death. RESULTS A total of 1,112 records were reviewed: 470 women (42.3%) and 642 men. Women were a median 8 years (interquartile range = 3 to 13 years) older than men, had higher rates of cardiovascular comorbidities, and were more likely to present with atypical symptoms such as weakness or dyspnea. On their index ED visits, 50.2% of women and 41.3% of men were admitted. At 30 days, 39 of 234 (16.7%) women and 55 of 377 (14.6%) men who were discharged at their index ED visits had made revisits, for a risk difference of 2.1% (95% confidence interval = -3.9% to 8.5%). There were no apparent sex differences in the use of acute rhythm control or in the appropriateness of anticoagulation decisions. ED LOS was similar between women and men, as were 30-day and 1-year stroke or death rates. CONCLUSIONS Female ED AFF patients were older, had more comorbidities, and were more likely to be admitted. However, the overall management and outcomes, including 30-day revisits, appeared to be similar to that of males, indicating that there appeared to be little sex-based discrepancy in ED care and outcomes.
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Affiliation(s)
- Frank Xavier Scheuermeyer
- Department of Emergency Medicine; St. Paul's Hospital and the University of British Columbia; Vancouver BC Canada
| | - Martha Mackay
- Division of Cardiology; Department of Medicine; St. Paul's Hospital and the University of British Columbia; Vancouver BC Canada
| | - Jim Christenson
- Department of Emergency Medicine; St. Paul's Hospital and the University of British Columbia; Vancouver BC Canada
| | - Eric Grafstein
- Department of Emergency Medicine; Mount St. Joseph's Hospital and the University of British Columbia; Vancouver BC Canada
| | - Reza Pourvali
- Department of Emergency Medicine; St. Paul's Hospital and the University of British Columbia; Vancouver BC Canada
| | - Claire Heslop
- Department of Emergency Medicine; St. Paul's Hospital and the University of British Columbia; Vancouver BC Canada
| | - Jan MacPhee
- Department of Emergency Medicine; St. Paul's Hospital and the University of British Columbia; Vancouver BC Canada
| | - John Ward
- Department of Emergency Medicine; St. Paul's Hospital and the University of British Columbia; Vancouver BC Canada
| | - Brett Heilbron
- Division of Cardiology; Department of Medicine; St. Paul's Hospital and the University of British Columbia; Vancouver BC Canada
| | - Lorraine McGrath
- Division of Cardiology; Department of Medicine; St. Paul's Hospital and the University of British Columbia; Vancouver BC Canada
| | - Karin Humphries
- Division of Cardiology; Department of Medicine; St. Paul's Hospital and the University of British Columbia; Vancouver BC Canada
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Lardaro T, Self WH, Barrett TW. Thirty-day mortality in ED patients with new onset atrial fibrillation and actively treated cancer. Am J Emerg Med 2015; 33:1483-8. [PMID: 26283615 DOI: 10.1016/j.ajem.2015.07.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 07/09/2015] [Accepted: 07/10/2015] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Studies suggest that inflammatory, autonomic, and coagulation alterations associated with cancer may increase incident atrial fibrillation (AF). New-onset AF is associated with increased mortality in other nonneoplastic disease processes. We investigated the association of active cancer with 30-day mortality in emergency department (ED) patients with new-onset AF. METHODS We conducted an analysis within an observational cohort study at a tertiary care hospital that included ED patients with new-onset AF. The exposure variable was presence of active cancer. We defined active cancer as the patient received chemotherapy, radiotherapy, or recent cancer-related surgery within 90 days of the ED visit. The primary outcome was 30-day mortality. Logistic regression was used to analyze the association between cancer status and 30-day mortality adjusting for patient age and sex. RESULTS During the 5.5-year study period, 420 patients with new-onset AF were included in our cohort, including 37 (8.8%) with active cancer. Patients with active cancer had no clinically relevant differences in their hemodynamic stability. Among the 37 patients with active cancer, 9 (24%) died within 30 days. Of the 383 patients without active cancer, 11 (3%) died within 30 days. After adjusting for age and sex, active cancer was an independent predictor of 30-day mortality, with an adjusted odds ratio of 10.8 (95% confidence interval, 3.8-31.1). CONCLUSIONS Among ED patients with new-onset AF, active cancer appears to be associated with 11-fold increased odds of 30-day mortality; new-onset AF may represent progressive organ dysfunction leading to an increased risk of short-term mortality in patients with cancer.
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Affiliation(s)
- Thomas Lardaro
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Tyler W Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN.
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White JL, Heller MB, Kahoud RJ, Slade D, Harding JD. Performance of an expedited rhythm control method for recent onset atrial fibrillation in a community hospital. Am J Emerg Med 2015; 33:957-62. [DOI: 10.1016/j.ajem.2015.03.059] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Revised: 03/27/2015] [Accepted: 03/27/2015] [Indexed: 11/30/2022] Open
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Scheuermeyer FX, Pourvali R, Rowe BH, Grafstein E, Heslop C, MacPhee J, McGrath L, Ward J, Heilbron B, Christenson J. Emergency Department Patients With Atrial Fibrillation or Flutter and an Acute Underlying Medical Illness May Not Benefit From Attempts to Control Rate or Rhythm. Ann Emerg Med 2015; 65:511-522.e2. [DOI: 10.1016/j.annemergmed.2014.09.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 08/27/2014] [Accepted: 09/15/2014] [Indexed: 11/25/2022]
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Barrett TW, Jenkins CA, Self WH. Validation of the Risk Estimator Decision Aid for Atrial Fibrillation (RED-AF) for predicting 30-day adverse events in emergency department patients with atrial fibrillation. Ann Emerg Med 2015; 65:13-21.e3. [PMID: 25245277 PMCID: PMC4275362 DOI: 10.1016/j.annemergmed.2014.08.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 07/17/2014] [Accepted: 08/06/2014] [Indexed: 10/24/2022]
Abstract
STUDY OBJECTIVE In the United States, nearly 70% of emergency department (ED) visits for atrial fibrillation result in hospitalization. The incidence of serious 30-day adverse events after an ED evaluation for atrial fibrillation remains low. This study's goal was to prospectively validate our previously reported Risk Estimator Decision Aid for Atrial Fibrillation (RED-AF) model for estimating a patient's risk of experiencing a 30-day adverse event. METHODS This was a prospective cohort study, which enrolled a convenience sample of ED patients presenting with atrial fibrillation. RED-AF, previously derived from a retrospective cohort of 832 patients, assigns points according to age, sex, coexisting disease (eg, heart failure, hypertension, chronic obstructive pulmonary disease), smoking, home medications (eg, β-blocker, diuretic), physical examination findings (eg, dyspnea, palpitations, peripheral edema), and adequacy of ED ventricular rate control. Primary outcome was occurrence of greater than or equal to 1 atrial fibrillation-related adverse outcome (ED visits, rehospitalization, cardiovascular complications, death) within 30 days. We identified a clinically relevant threshold and measured RED-AF's performance in this prospective cohort, assessing its calibration, discrimination, and diagnostic accuracy. RESULTS The study enrolled 497 patients between June 2010 and February 2013. Of these, 120 (24%) had greater than or equal to 1 adverse event within 30 days. A RED-AF score of 87 was identified as an optimal threshold, resulting in sensitivity and specificity of 96% (95% confidence interval [CI] 91% to 98%) and 19% (95% CI 15% to 23%), respectively. Positive and negative predictive values were 27% (95% CI 23% to 32%) and 93% (95% CI 85% to 97%), respectively. The c statistic for RED-AF was 0.65 (95% CI 0.59 to 0.71). CONCLUSION In this separate validation cohort, RED-AF performed moderately well and similar to the original derivation cohort for identifying the risk of short-term atrial fibrillation-related adverse events in ED patients receiving a diagnosis of atrial fibrillation.
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Affiliation(s)
- Tyler W Barrett
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, TN.
| | - Cathy A Jenkins
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, TN
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GRÖNBERG TONI, HARTIKAINEN JUHAEK, NUOTIO ILPO, BIANCARI FAUSTO, VASANKARI TUIJA, NIKKINEN MARKO, YLITALO ANTTI, AIRAKSINEN KEJUHANI. Can We Predict the Failure of Electrical Cardioversion of Acute Atrial Fibrillation? The FinCV Study. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2014; 38:368-75. [DOI: 10.1111/pace.12561] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 09/21/2014] [Accepted: 10/29/2014] [Indexed: 11/30/2022]
Affiliation(s)
- TONI GRÖNBERG
- Heart Center; Turku University Hospital and University of Turku; Turku Finland
| | | | - ILPO NUOTIO
- Division of Medicine; Department of Acute Internal Medicine; Turku University Hospital; Turku Finland
| | - FAUSTO BIANCARI
- Department of Surgery; Oulu University Hospital; Oulu Finland
| | - TUIJA VASANKARI
- Heart Center; Turku University Hospital and University of Turku; Turku Finland
| | - MARKO NIKKINEN
- Heart Center; Kuopio University Hospital; Kuopio Finland
| | - ANTTI YLITALO
- Heart Center; Satakunta Central Hospital; Pori Finland
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Yang YM, Shao XH, Zhu J, Zhang H, Liu Y, Gao X, Yu LT, Liu LS, Zhao L, Yu PF, Zhang H, He Q, Gu XD. One-Year Outcomes of Emergency Department Patients With Atrial Fibrillation: A Prospective, Multicenter Registry in China. Angiology 2014; 66:745-52. [PMID: 25344528 DOI: 10.1177/0003319714553936] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
There is lack of data about patient characteristics, practice patterns, and long-term adverse outcomes in patients with atrial fibrillation (AF) attending emergency departments (EDs) in China. A total of 2016 patients from 20 representative EDs were included. During 1 year, all-cause mortality was 291 (14.6%) cases, stroke/noncentral nervous system systemic embolism rate was 159 (8.0%) cases, and major bleeding was 26 (1.3%) cases. Heart failure, the major cause of mortality, accounted for 43.0% of deaths. Of 375 (18.6%) patients who used warfarin at baseline, only 217 (57.9%) patients were still on anticoagulation therapy during 1-year follow-up. Compared with the patients who continued on warfarin, the mortality rate was higher in those who did not continue (15.9% vs 5.5%, P < .001). Patients seen in ED with AF appear to have a high incidence rate of long-term all-cause mortality and inadequate anticoagulation rate.
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Affiliation(s)
- Yan-Min Yang
- Emergency and Intensive Care Center, Fuwai Hospital, Chinese Academy Of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xing-Hui Shao
- Emergency and Intensive Care Center, Fuwai Hospital, Chinese Academy Of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Zhu
- Emergency and Intensive Care Center, Fuwai Hospital, Chinese Academy Of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Han Zhang
- Emergency and Intensive Care Center, Fuwai Hospital, Chinese Academy Of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yao Liu
- Emergency and Intensive Care Center, Fuwai Hospital, Chinese Academy Of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin Gao
- Emergency and Intensive Care Center, Fuwai Hospital, Chinese Academy Of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Li-Tian Yu
- Emergency and Intensive Care Center, Fuwai Hospital, Chinese Academy Of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Li-Sheng Liu
- Emergency and Intensive Care Center, Fuwai Hospital, Chinese Academy Of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Li Zhao
- Department of Emergency, Fu Xing Hospital, Capital Medical University, Beijing, China
| | - Peng-Fei Yu
- Department of Cardiology, Pingdu People's Hospital, Pingdu, Shandong, China
| | - Hua Zhang
- Department of Emergency, Qingdao Municipal Hospital, Qingdao, Shandong, China
| | - Qing He
- Department of Emergency, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiao-Dan Gu
- Department of Emergency, Sixth People's Hospital of Chengdu, Chengdu, Sichuan, China
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Barrett TW, Marill KA. Anticoagulation for Emergency Department Patients With Atrial Fibrillation: Is Our Duty to Inform or Prescribe? Ann Emerg Med 2013; 62:566-8. [DOI: 10.1016/j.annemergmed.2013.05.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Revised: 05/29/2013] [Accepted: 05/29/2013] [Indexed: 10/26/2022]
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Scheuermeyer FX, Innes G, Pourvali R, Dewitt C, Grafstein E, Heslop C, MacPhee J, Ward J, Heilbron B, McGrath L, Christenson J. Missed Opportunities for Appropriate Anticoagulation Among Emergency Department Patients With Uncomplicated Atrial Fibrillation or Flutter. Ann Emerg Med 2013; 62:557-565.e2. [DOI: 10.1016/j.annemergmed.2013.04.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 03/16/2013] [Accepted: 04/04/2013] [Indexed: 11/25/2022]
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Barrett TW, Self WH, Jenkins CA, Storrow AB, Heavrin BS, McNaughton CD, Collins SP, Goldberger JJ. Predictors of regional variations in hospitalizations following emergency department visits for atrial fibrillation. Am J Cardiol 2013; 112:1410-6. [PMID: 23972347 DOI: 10.1016/j.amjcard.2013.07.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 07/12/2013] [Accepted: 07/12/2013] [Indexed: 12/31/2022]
Abstract
The emergency department (ED) is often where atrial fibrillation (AF) is first detected and acutely treated and affected patients dispositioned. We used the Nationwide Emergency Department Sample to estimate the percentage of visits resulting in hospitalization and investigate associations between patient and hospital characteristics with hospitalization at the national and regional levels. We conducted a cross-sectional study of adults with AF listed as the primary ED diagnosis in the 2007 to 2009 Nationwide Emergency Department Sample. We performed multivariate logistic regression analyses investigating the associations between prespecified patient and hospital characteristics with hospitalization. From 2007 to 2009, there were 1,320,123 weighted ED visits for AF, with 69% hospitalized nationally. Mean regional hospitalization proportions were: Northeast (74%), Midwest (68%), South (74%), and West (57%). The highest odds ratios for predicting hospitalization were heart failure (3.85, 95% confidence interval [CI] 3.66 to 4.02), chronic obstructive pulmonary disease (2.47, 95% CI 2.34 to 2.61), and coronary artery disease (1.65, 95% CI 1.58 to 1.73). After adjusting for age, privately insured (0.77, 95% CI 0.73 to 0.81) and self-pay (0.77 95% CI 0.66 to 0.90) patients had lower odds compared with Medicare recipients, whereas Medicaid (1.21, 95% CI 1.11 to 1.32) patients tended to have higher odds. Patients living in low-income zip codes (1.18, 95% CI 1.12 to 1.25) and patients treated at large metropolitan hospitals (1.75, 95% CI 1.59 to 1.93) had higher odds. In conclusion, our analysis showed considerable regional variation in the management of patients with AF in the ED and in associations between patient socioeconomic and hospital characteristics with ED disposition; adapting best practices from among these variations in management could reduce hospitalizations and health-care expenses.
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Affiliation(s)
- Tyler W Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
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Grönberg T, Nuotio I, Nikkinen M, Ylitalo A, Vasankari T, Hartikainen JE, Airaksinen KJ. Arrhythmic complications after electrical cardioversion of acute atrial fibrillation: The FinCV study. ACTA ACUST UNITED AC 2013; 15:1432-5. [DOI: 10.1093/europace/eut106] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Barrett TW, Self WH, Wasserman BS, McNaughton CD, Darbar D. Evaluating the HATCH score for predicting progression to sustained atrial fibrillation in ED patients with new atrial fibrillation. Am J Emerg Med 2013; 31:792-7. [PMID: 23478104 DOI: 10.1016/j.ajem.2013.01.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Revised: 01/19/2013] [Accepted: 01/21/2013] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES Atrial fibrillation (AF) is often first detected in the emergency department (ED). Not all AF patients progress to sustained AF (ie, episodes lasting >7 days), which is associated with increased morbidity. The HATCH score stratifies patients with paroxysmal AF according to their risk for progression to sustained AF within 1 year. The HATCH score has previously never been tested in ED patients. We evaluated the accuracy of the HATCH score to predict progression to sustained AF within 1 year of initial AF diagnosis in the ED. METHODS We conducted a retrospective cohort study of 253 ED patients with new onset AF and known rhythm status for 1 year following the initial AF detection. The exposure variable was the HATCH score at initial ED evaluation. The primary outcome was rhythm status at 1 year following initial AF diagnosis. We constructed a receiver operating characteristic curve and calculated the area under the curve to estimate the HATCH score's accuracy of predicting progression to sustained AF. RESULTS Overall, 61 (24%) of 253 of patients progressed to sustained AF within 1 year of initial detection, and the HATCH score receiver operating characteristic area under the curve was 0.62 (95% confidence interval, 0.54-0.70). CONCLUSIONS Among ED patients with new onset AF, the HATCH score was a modest predictor of progression to sustained AF. Because only 2 patients had a HATCH greater than 5, this previously recommended cut-point was not useful in identifying high-risk patients in this cohort. Refinement of this decision aid is needed to improve its prognostic accuracy in the ED population.
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Affiliation(s)
- Tyler W Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN 37232-4700, USA.
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Scheuermeyer FX, Grafstein E, Stenstrom R, Christenson J, Heslop C, Heilbron B, McGrath L, Innes G. Safety and efficiency of calcium channel blockers versus beta-blockers for rate control in patients with atrial fibrillation and no acute underlying medical illness. Acad Emerg Med 2013; 20:222-30. [PMID: 23517253 DOI: 10.1111/acem.12091] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2012] [Revised: 09/25/2012] [Accepted: 10/01/2012] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Many patients with atrial fibrillation (AF) are not candidates for rhythm control and may require rate control, typically with beta-blocking (BB) or calcium channel blocking (CCB) agents. Although these patients appear to have a low 30-day rate of stroke or death, it is unclear if one class of agent is safer or more effective. The objective was to determine whether BBs or CCBs would have a lower hospital admission rate and to measure 30-day safety outcomes including stroke, death, and emergency department (ED) revisits. METHODS This retrospective cohort study used a database from two urban EDs to identify consecutive patients with ED discharge diagnoses of AF from April 1, 2006, to March 31, 2010. Comorbidities, rhythms, management, and immediate outcomes were obtained by manual chart review, and patients with acute underlying medical conditions were excluded by predefined criteria. Patients managed only with rate control agents were eligible for review, and patients receiving BB agents were compared to those receiving CCB agents. The primary outcome was the proportion of patients requiring hospital admission; secondary outcomes included the ED length of stay (LOS), the proportion of patients having adverse events, the proportion of patients returning within 7 or 30 days, and the number of patients having a stroke or dying within 30 days. RESULTS A total of 259 consecutive patients were enrolled, with 100 receiving CCBs and 159 receiving BBs. Baseline demographics and comorbidities were similar. Twenty-seven percent of BB patients were admitted, and 31.0% of CCB patients were admitted (difference = 4.0%, 95% confidence interval [CI] = -7.7% to 16.1%), and there were no significant differences in ED LOS, adverse events, or 7- or 30-day ED revisits. One patient who received metoprolol had a stroke, and one patient who received diltiazem died within 30 days. CONCLUSIONS In this cohort of ED patients with AF and no acute underlying medical illness who underwent rate control only, patients receiving CCBs had similar hospital admission rates to those receiving BBs, while both classes of medications appeared equally safe at 30 days. Both CCBs and BBs are acceptable options for rate control.
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Affiliation(s)
- Frank Xavier Scheuermeyer
- Department of Emergency Medicine; St. Paul's Hospital and the University of British Columbia; Vancouver BC Canada
| | - Eric Grafstein
- Department of Emergency Medicine; Mount St Joseph's Hospital and the University of British Columbia; Vancouver BC Canada
| | - Rob Stenstrom
- Department of Emergency Medicine; St. Paul's Hospital and the University of British Columbia; Vancouver BC Canada
| | - Jim Christenson
- Department of Emergency Medicine; St. Paul's Hospital and the University of British Columbia; Vancouver BC Canada
| | - Claire Heslop
- Department of Emergency Medicine; St. Paul's Hospital and the University of British Columbia; Vancouver BC Canada
| | - Brett Heilbron
- Division of Cardiology; St Paul's Hospital and the University of British Columbia; Vancouver BC Canada
| | - Lorraine McGrath
- Division of Cardiology; St Paul's Hospital and the University of British Columbia; Vancouver BC Canada
| | - Grant Innes
- Division of Emergency Medicine; Foothills Hospital and the University of Calgary; Calgary AB Canada
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