Acute Emergency Department Management of AF: Scope for a Reduction in Hospital Admissions

Abstract

Introduction: Atrial fibrillation (AF) is significantly more prevalent in men than in women. Significant differences in left atrial (LA) and pulmonary vein (PV) electrophysiology that may predispose to AF have been demonstrated in animal studies but there are few data regarding gender-based differences in human electrophysiology.Methods: Detailed studies of LA and PV electrophysiology were undertaken in 66 consecutive patients with AF undergoing ablation. ERP was measured at 3 LA and 2 PV sites at two cycle lengths. The LA was divided into six anatomic regions (appendage, roof, floor, septum, lateral and posterior). Activation time (AT) and voltage were analysed globally and regionally. PV sleeve length was measured from PV electrogram extent and AT was corrected for length as a marker of conduction. Data were analysed for the presence of systematic differences between male and female patients.Results: Male (n = 53) and female groups (n = 13) were well matched for age (58 vs 62 years, p = ns), LVEF (59 vs 60%, p = ns) and LA diameter (4.4 vs 4.1 cm, p = ns). No consistent differences were observed for any parameter. Representative data are presented: Heart, Lung and Circulation CSANZ 2012 Abstracts 2012;21:S1-S142 (b) history of embolism (including stroke/TIA), (c) renal failure, (d) malignancy, (e) hemodynamic instability and (f) AF associated with another medical reason necessitating admission (e.g. underlying infection).Results: Seventy-one percent (n = 175) of patient presenting to the ED were admitted to hospital, with a consequent median length of stay of 2 [1-4] days. Older age (p = 0.01), clinical history of hypertension (p = 0.006) and out of hours presentation time (p = 0.02) were significant predictors of hospital admission, whilst the presence of diabetes mellitus (p = 0.10), impaired renal function (p = 0.08) and congestive heart failure (p = 0.16) trended toward predicting hospital admission. Nineteen percent of the patients admitted to hospital were considered to be low risk.Conclusion: Older age, out of hours presentation time and hypertension predicted hospitalisation for acute AF; however, ∼1 in 5 hospitalisations were for low risk patients. Treating a low risk patient in the ED could save ∼$2000 per presentation, which extrapolates to ∼13 million dollar saving Australia wide every year. http://dx.