Variation in Management of Recent-Onset Atrial Fibrillation and Flutter Among Academic Hospital Emergency Departments

Stiell, Ian G.; Clement, Catherine M.; Brison, Robert J.; Rowe, Brian H.; Borgundvaag, Bjug; Langhan, Trevor; Lang, Eddy; Magee, Kirk; Stenstrom, Robert; Perry, Jeffrey J.; Birnie, David H.; Wells, George A.

doi:10.1016/j.annemergmed.2010.07.005

Cited by 111 publications

(109 citation statements)

References 42 publications

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“…Provider characteristics have been found to be more strongly associated than patient characteristics with the investigation and management of atrial fibrillation, 23,24 myocardial infarction, 25,26 and other conditions 27 . In contrast, our findings suggest that patient characteristics, not provider characteristics, drive ED management decisions for discharged hypertensive patients.…”

Section: Discussionmentioning

confidence: 99%

Management of Discharged Emergency Department Patients with a Primary Diagnosis of Hypertension: A Multicentre Study

Cho

Austin

Atzema

2015

CJEM

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Introduction: Many patients are seen in the emergency department (ED) for hypertension, and the numbers will likely increase in the future. Given limited evidence to guide the management of such patients, the practice of one's peers provides a de facto standard. Methods: A survey was distributed to emergency physicians during academic rounds at three community and four tertiary EDs. The primary outcome measure was the proportion of participants who had a blood pressure (BP) threshold at which they would offer a new antihypertensive prescription to patients they were sending home from the ED. Secondary outcomes included patient-and providerlevel factors associated with initiating an antihypertensive based on clinical vignettes of a 69-year-old man with two levels of hypertension (160/100 vs 200/110 mm Hg), as well as the recommended number of days after which to follow up with a primary care provider following ED discharge. Results: All 81 surveys were completed (100%). Half (51.9%; 95% CI 40.5-63.1) of participants indicated that they had a systolic BP threshold for initiating an antihypertensive, and 55.6% (95% CI 44.1-66.6) had a diastolic threshold: mean systolic threshold was 199 mm Hg (SD 19) while diastolic was 111 mm Hg (SD 8). A higher BP (OR 12.9; 95% CI 7.5-22.2) and more patient comorbidities (OR 3.0; 95% CI 2.1-4.3) were associated with offering an antihypertensive prescription, while physician years of practice, certification type, and hospital type were not. Participants recommended follow-up care within a median 7.0 and 3.0 days for the patient with lower and higher BP levels, respectively. Conclusions: Half of surveyed emergency physicians report having a BP threshold to start an antihypertensive; BP levels and number of patient comorbidities were associated with a modification of the decision, while physician characteristics were not. Most physicians recommended follow-up care within seven days of ED discharge.

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Section: Discussionmentioning

confidence: 99%

Management of Discharged Emergency Department Patients with a Primary Diagnosis of Hypertension: A Multicentre Study

Cho

Austin

Atzema

2015

CJEM

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“…4 Much of the research and guidelines have been developed in, and have almost exclusively been applied to, the outpatient or postoperative environment. The most recent…”

Section: Importancementioning

confidence: 99%

Use of rate control medication before cardioversion of recent-onset atrial fibrillation or flutter in the emergency department is associated with reduced success rates

Blecher

Stiell

Rowe

et al. 2012

CJEM

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Objective: It is believed that when patients present to the emergency department (ED) with recent-onset atrial fibrillation or flutter (RAFF), controlling the ventricular rate before cardioversion improves the success rate. We evaluated the influence of rate control medication and other variables on the success of cardioversion.Methods: This secondary analysis of a medical records review comprised 1,068 patients with RAFF who presented to eight Canadian EDs over 12 months. Univariate analysis was performed to find associations between predictors of conversion to sinus rhythm including use of rate control, rhythm control, and other variables. RÉ SUMÉObjectif: On croit que lorsqu'un patient se pré sente au service des urgences (SU) en é tat de fibrillation auriculaire (flutter) ré cente, le contrôle de la fré quence ventriculaire avant l'amé lioration de la cardioversion augmente le taux de ré ussite. Nous avons é valué l'influence des mé dicaments de contrô le de la fré quence et d'autres variables sur l'amé lioration de la cardioversion. Mé thodes: Cette deuxiè me analyse des dossiers mé dicaux porte sur 1 068 patients en é tat de fibrillation auriculaire (flutter) ré cente qui se sont pré senté s dans huit services des urgences au Canada au cours des 12 derniers mois. Une analyse univarié e a é té effectué e afin d'é tablir des liens entre les pré dicteurs de conversion et le rythme sinusal, y compris le contrô le de la fré quence, le contrô le du rythme, et d'autres variables. Les variables pré dictives ont é té inté gré es au modè le à plusieurs variables afin de calculer les ratios d'incidence approché s (RIA) redressé s associé s à la ré ussite de la cardioversion. (IC 95 % 0,83). Les RIA pour les facteurs lié s aux cardioversions pharmacologiques ré ussies é taient l'utilisation de mé dicaments de contrô le de la fré quence, 1,29 (IC 95 % 0,82-2,03); le sexe fé minin, 2,37 (IC 95 % 1,50-3,72); et l'utilisation de la procaïnamide, 2,32 (CI 95 % 1,43-3,74).Conclusion: Nous avons dé montré un taux de ré ussite plus faible des cardioversions pour les patients en é tat de fibrillation auriculaire (flutter) ré cente lorsque ces derniers avaient pré alablement pris des mé dicaments de contrô le de la fré quence ou du rythme. Les mé dicaments de contrô le de la fré quence n'é taient pas associé s à un taux de ré ussite plus é levé des cardioversions pharmacologiques, contrairement à la procaïnamide. Il faudrait é viter de ralentir la fré quence ventriculaire avant la cardioversion.Keywords: atrial fibrillation, cardioversion, rate control Atrial fibrillation (AF) affects an estimated 2.2 million Americans and is present in 8 to 10% of those over 80 years old.1 The major morbidity associated with AF or atrial flutter (AFL) is from thromboembolism, particularly to the cerebral circulation. In managing this risk, one of two competing management strategies is recommended: rate control or rhythm control.Symptomatic AF or AFL with rapid ventricular response is a common presentation to emergency departments (ED...

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“…17 Similarly, for patients presenting with atrial fibrillation, the rate of admission varied amongst Canada and U.S. hospitals, with U.S. EDs admitting more patients to short-stay ED observational units. 18,19 This study urges policymakers to consider shifting resources from inpatient hospital services toward risk stratification and outpatient services. Differences in availability of timely outpatient follow-up may lead to differences in admission and mortality.…”

Section: Discussionmentioning

confidence: 99%

Comparison of management and outcomes of ED patients with acute decompensated heart failure between the Canadian and United States’ settings

Lai

Tenpenny

Nestler

et al. 2015

CJEM

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IntroductionThe objective of this study was to compare the emergency department (ED) management and rate of admission of acute decompensated heart failure (ADHF) between two hospitals in Canada and the United States and to compare the outcomes of these patients.MethodsThis was a health records review of adults presenting with ADHF to two EDs in Canada and the United States between January 1 and April 30, 2010. Outcome measures were admission to the hospital, myocardial infarction (MI), and death or relapse rates to the ED. Data were analysed using descriptive, univariate and multivariate analyses.ResultsIn total, 394 cases were reviewed and 73 were excluded. Comparing 156 Canadian to 165 U.S. patients, respectively, mean age was 76.0 and 75.8 years; male sex was 54.5% and 52.1%. Canadian and U.S. ED treatments were noninvasive ventilation 7.7% v. 12.8% (p=0.13); IV diuretics 77.6% v. 36.0% (p<0.001); IV nitrates 4.5% v. 6.7% (p=0.39). There were significant differences in rate of admission (50.6% v. 95.2%, p<0.001) and length of stay in ED (6.7 v. 3.0 hours, p<0.001). Proportion of Canadian and U.S. patients who died within 30 days of the ED visit was 5.1% v. 9.7% (p=0.12); relapsed to the ED within 30 days was 20.8% v. 17.5% (p=0.5); and had MI within 30 days was 2.0% v. 1.9% (p=1.0).ConclusionsThe U.S. and Canadian centres saw ADHF patients with similar characteristics. Although the U.S. site had almost double the admission rate, the outcomes were similar between the sites, which question the necessity of routine admission for patients with ADHF.

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Variation in Management of Recent-Onset Atrial Fibrillation and Flutter Among Academic Hospital Emergency Departments

Cited by 111 publications

References 42 publications

Management of Discharged Emergency Department Patients with a Primary Diagnosis of Hypertension: A Multicentre Study

Management of Discharged Emergency Department Patients with a Primary Diagnosis of Hypertension: A Multicentre Study

Use of rate control medication before cardioversion of recent-onset atrial fibrillation or flutter in the emergency department is associated with reduced success rates

Comparison of management and outcomes of ED patients with acute decompensated heart failure between the Canadian and United States’ settings

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