Emergency Department Management of Atrial Fibrillation and Flutter and Patient Quality of Life at One Month Postvisit

Ballard, Dustin; Reed, Mary; Singh, Nimmie; Rauchwerger, Adina S.; Hamity, Courtnee; Warton, E. Margaret; Chettipally, Uli K.; Mark, Dustin G.; Vinson, David R.

doi:10.1016/j.annemergmed.2015.04.011

Cited by 20 publications

(16 citation statements)

References 44 publications

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“…Although ED‐based outcomes such as LOS and adverse events have been described, the QoL in ED AF patients has been minimally investigated . Although AF in this group may not be “dangerous” in terms of death, stroke, or hospitalization, symptoms can be profoundly unpleasant and interfere with daily activities and enjoyment of life for both patients and families.…”

Section: Discussionmentioning

confidence: 99%

“…Our results cannot be extrapolated to patients with chronic AF, those at higher risk of stroke, those with acute underlying medical illnesses, or adults > 75 years of age, although such patients are not typically managed with rhythm control . Finally, the SF‐8 is a general health systems questionnaire and has not been validated in this cohort of patients, although AF‐specific QoL measures have been recently developed . Neither patient nor physician satisfaction was assessed, nor were costs.…”

Section: Limitationsmentioning

confidence: 94%

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A Multicenter Randomized Trial to Evaluate a Chemical‐first or Electrical‐first Cardioversion Strategy for Patients With Uncomplicated Acute Atrial Fibrillation

Scheuermeyer¹,

Andolfatto

Christenson

et al. 2019

Academic Emergency Medicine

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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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Section: Discussionmentioning

confidence: 99%

Section: Limitationsmentioning

confidence: 94%

A Multicenter Randomized Trial to Evaluate a Chemical‐first or Electrical‐first Cardioversion Strategy for Patients With Uncomplicated Acute Atrial Fibrillation

Scheuermeyer¹,

Andolfatto

Christenson

et al. 2019

Academic Emergency Medicine

View full text Add to dashboard Cite

show abstract

“…Potential drivers of this practice include prior research suggesting no benefit in outcomes from a preference of rhythm over rate control, the perceived or actual burden on ED resources to perform cardioversion, prior versions of specialty society guidelines, and lack of payer scrutiny of short‐stay AF inpatient hospitalizations or readmissions versus other conditions such as chest pain, syncope, and congestive heart failure . More recently, the recognition of patient preference for returning to sinus rhythm has been added to the reasons to advocate for an early cardioversion strategy . Nevertheless, the experience of other countries can provide an example of alternative evidence‐based management that results in fewer hospitalizations without evidence of worse outcomes, a result relevant to U.S. EDs faced with heavy burdens of inpatient crowding and ED boarding …”

Section: Discussionmentioning

confidence: 99%

Creation and Implementation of an Outpatient Pathway for Atrial Fibrillation in the Emergency Department Setting: Results of an Expert Panel

Baugh

Clark

Wilson

et al. 2018

Academic Emergency Medicine

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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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“…15 A cardioversion may feel very effective to a patient (particularly electrical, with concomitant procedural sedation), but at 30 days there was no independent difference in validated measures of atrial fibrillation symptoms, activity limitations, and treatment satisfaction between these patients and those who received rate-control therapy. 3 Does this mean we shouldn't offer ED cardioversion? Or rather should we offer it to everyone, so that we can increase our patient satisfaction scores?…”

mentioning

confidence: 98%

Atrial Fibrillation: Would You Prefer a Pill or 150 Joules?

Atzema

2015

Annals of Emergency Medicine

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Emergency Department Management of Atrial Fibrillation and Flutter and Patient Quality of Life at One Month Postvisit

Cited by 20 publications

References 44 publications

A Multicenter Randomized Trial to Evaluate a Chemical‐first or Electrical‐first Cardioversion Strategy for Patients With Uncomplicated Acute Atrial Fibrillation

A Multicenter Randomized Trial to Evaluate a Chemical‐first or Electrical‐first Cardioversion Strategy for Patients With Uncomplicated Acute Atrial Fibrillation

Creation and Implementation of an Outpatient Pathway for Atrial Fibrillation in the Emergency Department Setting: Results of an Expert Panel

Atrial Fibrillation: Would You Prefer a Pill or 150 Joules?

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