BackgroundAtrial fibrillation (AF) is the most common sustained cardiac arrhythmia resulting in mortality and morbidity. Gaps in oral anticoagulation and education of patients regarding AF have been identified as areas that require improvement.Methods and ResultsA before‐and‐after study of 433 patients with newly diagnosed AF in the 3 emergency departments in Nova Scotia from January 1, 2011 until January 31, 2014 was performed. The “before” phase underwent the usual‐care pathway for AF management; the “after” phase was enrolled in a nurse‐run, physician‐supervised AF clinic. The primary outcome was a composite of death, cardiovascular hospitalization, and AF‐related emergency department visits. A propensity analysis was performed to account for differences in baseline characteristics.ResultsA total of 185 patients were enrolled into the usual‐care group, and 228 patients were enrolled in the AF clinic group. The mean age was 64±15 years and 44% were women. In a propensity‐matched analysis, the primary outcome occurred in 44 (26.2%) patients in the usual‐care group and 29 (17.3%) patients in the AF clinic group (odds ratio 0.71; 95% CI [0.59, 1]; P=0.049) at 12 months. Prescription of oral anticoagulation was increased in the CHADS 2 ≥2 group (88.4% in the AF clinic versus 58.5% in the usual‐care group, P<0.01).ConclusionsAdoption of this integrated management approach for the burgeoning population of AF may provide an overall benefit to cardiovascular morbidity and mortality.

Background— Underuse of implantable defibrillators has been previously noted in patients at risk for sudden cardiac death, as well as for survivors of sudden cardiac death. We sought to determine the utilization rates in a primary prevention implantable cardioverter-defibrillator (ICD)–eligible population and mortality in this group compared with a group that had undergone implantation of this therapy. Methods and Results— A retrospective cohort of patients from April 1, 2006, to December 31, 2009, was used to define a primary prevention ICD-eligible population. Two groups were compared on the basis of ICD implantation (no-ICD versus ICD). The primary outcome measure was mortality. Of the 717 patients found to be potentially eligible for a primary prevention ICD, 116 (16%) were referred. The remaining cohort of 601 patients were compared with an existing cohort of primary prevention ICD patients (n=290). A significant survival benefit was associated with primary prevention ICD implantation (hazard ratio, 0.46; 95% CI [0.33–0.64]; P <0.0001). When adjusted for prespecified variables known to be associated with overall mortality and propensity score, a similar survival benefit was seen (hazard ratio, 0.59; 95% CI [0.40–0.87]; P =0.01). Appropriate ICD therapy occurred in 26% of those in the ICD group, during a mean follow-up of 2.7 years. Conclusions— A significant mortality benefit was observed for patients who underwent primary prevention ICD implantation compared with those who did not. Vigilance is required to ensure that patients eligible for primary prevention ICDs are appropriately referred and assessed to allow such patients to benefit from this life-saving therapy.

This case study of an emergency medicine blog quantifies the reach and engagement of social-media-enabled learning in emergency medicine.

Background: To facilitate ablation of ventricular tachycardia (VT), an automated localization system to identify the site of origin of left ventricular activation in real time using the 12-lead ECG was developed. The objective of this study was to prospectively assess its accuracy. Methods: The automated site of origin localization system consists of 3 steps: (1) localization of ventricular segment based on population templates, (2) population-based localization within a segment, and (3) patient-specific site localization. Localization error was assessed by the distance between the known reference site and the estimated site. Results: In 19 patients undergoing 21 catheter ablation procedures of scar-related VT, site of origin localization accuracy was estimated using 552 left ventricular endocardial pacing sites pooled together and 25 VT-exit sites identified by contact mapping. For the 25 VT-exit sites, localization error of the population-based localization steps was within 10 mm. Patient-specific site localization achieved accuracy of within 3.5 mm after including up to 11 pacing (training) sites. Using 3 remotes (67.8±17.0 mm from the reference VT-exit site), and then 5 close pacing sites, resulted in localization error of 7.2±4.1 mm for the 25 identified VT-exit sites. In 2 emulated clinical procedure with 2 induced VTs, the site of origin localization system achieved accuracy within 4 mm. Conclusions: In this prospective validation study, the automated localization system achieved estimated accuracy within 10 mm and could thus provide clinical utility.