scholarly journals LO40: Safe anticoagulation initiation for atrial fibrillation in the emergency department (the SAFE pathway)

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S21-S21
Author(s):  
C. Kirwan ◽  
S. Ramsden ◽  
A. Kibria ◽  
J. Carter ◽  
X. Tong ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Emergency Department ◽  
Patient Outcomes ◽  
Canadian Cardiovascular Society ◽  
Chads2 Score ◽  
Arterial Embolism ◽  
Local Emergency Department ◽  
Multidisciplinary Group ◽  
Record Review

Background: Atrial fibrillation (AF) is a risk for stroke. The Canadian Cardiovascular Society advises patients who are CHADS65 positive should be started on oral anticoagulation (OAC). Our local emergency department (ED) review showed that only 16% of CHADS65 positive patients were started on OAC and that 2% of our patients were diagnosed with stroke within 90 days. We implemented a new pathway for initiation of OAC in the ED (the SAFE pathway). Aim Statement: We report the effectiveness and safety of the SAFE pathway for initiation of OAC in patients treated for AF in the ED. Measures & Design: A multidisciplinary group of physicians and pharmacist developed the SAFE pathway for patients who are discharged home from the ED with a diagnosis of AF. Step 1: contraindications to OAC, Step 2: CHADS65 score, Step 3: OAC dosing if indicated. The pathway triggers referral to AF clinic, family physician letter and follow up call from the ED pharmacist. Patients are followed for 90 days by a structured medical record review and a structured telephone interview. We record persistence with OAC, stroke, TIA, systemic arterial embolism and major bleeding (ISTH criteria). Patient outcomes are fed back to the treating ED physician. Evaluation/ Results: The SAFE pathway was introduced in two EDs in June 2018. In total, 177 patients have had the pathway applied. The median age was 70 (interquartile range (IQR) 61-78), 48% male, median CHADS2 score 2 (IQR 0-2). 19/177 patients (11%) had a contraindication to initiating OAC. 122 patients (69%) had no contraindication to OAC and were CHADS65 positive. Of these 122 patients, 109 were given a prescription for OAC (96 the correct dose, 9 too high a dose and 4 too low a dose). 6 patients declined OAC and the physician did not want to start OAC for 7 patients. 73/122 were contacted by phone at 90 days, 15 could not be reached and 34 have not completed 90 days of follow up since their ED visit. Of the 73 who were reached by phone after 90 days, 65 were still taking an anticoagulant. To date, 1 patient who declined OAC (CHADS2 score of 2) had a stroke within 90 days and one patient prescribed OAC had a gastrointestinal bleed. Discussion/Impact: The SAFE pathway appears safe and effective although we continue to evaluate and improve the process.

scholarly journals Rhythm and rate control of atrial fibrillation in the emergency department – A large community-based observational study

CJEM ◽  
2017 ◽  
Vol 20 (6) ◽  
pp. 834-840 ◽  
Author(s):  
Cameron J. Gilbert ◽  
Paul Angaran ◽  
Zana Mariano ◽  
Theresa Aves ◽  
Paul Dorian
Keyword(s):  
Atrial Fibrillation ◽  
Emergency Department ◽  
Rate Control ◽  
Primary Diagnosis ◽  
Left Ventricular ◽  
Rhythm Control ◽  
Chads2 Score ◽  
Control Factors ◽  
Wide Range ◽  
Canadian City

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.

scholarly journals Anticoagulant therapies for acute venous thromboembolism: a comparison between those discharged directly from the emergency department versus hospital in two Canadian cities

BMJ Open ◽  
2018 ◽  
Vol 8 (10) ◽  
pp. e022063 ◽  
Author(s):  
Tammy J Bungard ◽  
Bruce Ritchie ◽  
Jennifer Bolt ◽  
William M Semchuk
Keyword(s):  
Emergency Department ◽  
Pulmonary Embolism ◽  
Venous Thromboembolism ◽  
Severity Index ◽  
Vein Thrombosis ◽  
Risk Patients ◽  
Acute Venous Thromboembolism ◽  
Record Review ◽  
Deep Vein

ObjectiveTo compare the characteristics/management of acute venous thromboembolism (VTE) for patients either discharged directly from the emergency department (ED) or hospitalised throughout a year within two urban cities in Canada.DesignRetrospective medical record review.SettingHospitals in Edmonton, Alberta (n=4) and Regina, Saskatchewan (n=2) from April 2014 to March 2015.ParticipantsAll patients discharged from the ED or hospital with acute deep vein thrombosis or pulmonary embolism (PE). Those having another indication for anticoagulant therapy, pregnant/breast feeding or anticipated lifespan <3 months were excluded.Primary and secondary outcomesPrimarily, to compare proportion of patients receiving traditional therapy (parenteral anticoagulant±warfarin) relative to a direct oral anticoagulant (DOAC) between the two cohorts. Secondarily, to assess differences with therapy selected based on clot burden and follow-up plans postdischarge.Results387 (25.2%) and 665 (72.5%) patients from the ED and hospital cohorts, respectively, were included. Compared with the ED cohort, those hospitalised were older (57.3 and 64.5 years; p<0.0001), more likely to have PE (35.7% vs 83.8%) with a simplified Pulmonary Embolism Severity Index (sPESI) ≥1 (31.2% vs 65.2%), cancer (14.7% and 22.3%; p=0.003) and pulmonary disease (10.1% and 20.6%; p<0.0001). For the ED and hospital cohorts, similar proportions of patients were prescribed traditional therapies (72.6% and 71.1%) and a DOAC (25.8% and 27.4%, respectively). For the ED cohort, DOAC use was similar between those with a sPESI score of 0 and ≥1 (35.1% and 34.9%, p=0.98) whereas for those hospitalised lower risk patients were more likely to receive a DOAC (31.4% and 23.8%, p<0.055). Follow-up was most common with family physicians for those hospitalised (51.5%), while specialists/VTE clinic was most common for those directly discharged from the ED (50.6%).ConclusionsTraditional and DOAC therapies were proportionately similar between the ED and hospitalised cohorts, despite clear differences in patient populations and follow-up patterns in the community.

scholarly journals Acute cardiovascular events and all-cause mortality in patients with hyperthyroidism: a population-based cohort study

2017 ◽  
Vol 176 (1) ◽  
pp. 1-9 ◽  
Author(s):  
Olaf M Dekkers ◽  
Erzsébet Horváth-Puhó ◽  
Suzanne C Cannegieter ◽  
Jan P Vandenbroucke ◽  
Henrik Toft Sørensen ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Cohort Study ◽  
Ischemic Stroke ◽  
Cardiovascular Events ◽  
Population Based ◽  
Arterial Embolism ◽  
Registration System ◽  
Increased Risk ◽  
All Cause Mortality

Objective Several studies have shown an increased risk for cardiovascular disease (CVD) in hyperthyroidism, but most studies have been too small to address the effect of hyperthyroidism on individual cardiovascular endpoints. Our main aim was to assess the association among hyperthyroidism, acute cardiovascular events and mortality. Design It is a nationwide population-based cohort study. Data were obtained from the Danish Civil Registration System and the Danish National Patient Registry, which covers all Danish hospitals. We compared the rate of all-cause mortality as well as venous thromboembolism (VTE), acute myocardial infarction (AMI), ischemic and non-ischemic stroke, arterial embolism, atrial fibrillation (AF) and percutaneous coronary intervention (PCI) in the two cohorts. Hazard ratios (HR) with 95% confidence intervals (95% CI) were estimated. Results The study included 85 856 hyperthyroid patients and 847 057 matched population-based controls. Mean follow-up time was 9.2 years. The HR for mortality was highest in the first 3 months after diagnosis of hyperthyroidism: 4.62, 95% CI: 4.40–4.85, and remained elevated during long-term follow-up (>3 years) (HR: 1.35, 95% CI: 1.33–1.37). The risk for all examined cardiovascular events was increased, with the highest risk in the first 3 months after hyperthyroidism diagnosis. The 3-month post-diagnosis risk was highest for atrial fibrillation (HR: 7.32, 95% CI: 6.58–8.14) and arterial embolism (HR: 6.08, 95% CI: 4.30–8.61), but the risks of VTE, AMI, ischemic and non-ischemic stroke and PCI were increased also 2- to 3-fold. Conclusions We found an increased risk for all-cause mortality and acute cardiovascular events in patients with hyperthyroidism.

Abstract 171: Warfarin Use And Stroke Risk Among Patients With Nonvalvular Atrial Fibrillation In A Large Managed Care Population

2012 ◽  
Vol 5 (suppl_1) ◽  
Author(s):  
Steven B Deitelzweig ◽  
Erin Buysman ◽  
Brett Pinsky ◽  
Michael Lacey ◽  
Yonghua Jing ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Managed Care ◽  
Treatment Period ◽  
Real World ◽  
Warfarin Therapy ◽  
Stroke Risk ◽  
Nonvalvular Atrial Fibrillation ◽  
Chads2 Score ◽  
Warfarin Treatment

Introduction Warfarin discontinuation among real world nonvalvular atrial fibrillation (NVAF) patients is common. Hypothesis We hypothesized that in a managed care population, warfarin discontinuation is associated with increased stroke risk. Methods Patients who initiated warfarin therapy between Jan 2005 and Jun 2009 and had a healthcare claim related to AF within 30 days prior to the first warfarin claim, but no evidence of valvular disease, were included. Warfarin discontinuation was defined as a supply gap of >60 days without evidence of International Normalized Ratio (INR) measurements. Follow-up was divided into periods of warfarin treatment and discontinuation. Stroke events were identified based on claims for inpatient stays with a primary diagnosis for stroke or transient ischemic attack (TIA). Cox proportional hazards models were constructed to assess the relationship between warfarin discontinuation and incident stroke while adjusting for baseline demographics, stroke and bleeding risk, and comorbidities, as well as time-dependent antiplatelet use, stroke, and bleeding events in the prior warfarin treatment period. Results The mean (SD) age of the study sample (N=16,253) was 67±12 years; 64.8% was male. Mean CHADS2 score was 1.84±1.30; mean HAS-BLED score was 2.00±1.18. Half (51.4%) of patients discontinued warfarin therapy at least once and the overall sample had a mean of 1.87 warfarin treatment periods during a mean of 668 days follow-up. Approximately 1186 patients (7%) had a stroke or TIA at any site of service during follow-up. Risk of stroke significantly increased during warfarin discontinuation periods compared with therapy periods (HR 1.60; 95%CI 1.35-1.90; P<.0001). Stroke risk was significantly increased for patients with baseline CHADS2 score ≥2 (HR 2.69; 95%CI 1.44-5.03; P=.002), HAS-BLED score ≥3 (HR 1.46; 95%CI 1.05-2.05; P=.027), or who had a bleeding (HR 1.29; 95%CI 1.06-1.57; P=.013) or stroke event (HR 3.04; 95%CI 2.47-3.75; P<.0001) in the prior treatment period. Conclusions In the real world, over half of patients on anticoagulation therapy had treatment gaps or permanently discontinued therapy. These usage patterns, as well as prior bleeding, were associated with increased stroke risk.

P1885Cha2ds-2vasc score lacks of ability to predict mortality in patients attending the emergency department with atrial fibrillation in the presence of troponin i

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
M I Gonzalez Del Hoyo ◽  
G Cediel ◽  
A Carrasquer ◽  
G Bonet ◽  
K Vasquez-Nunez ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Emergency Department ◽  
Regression Analysis ◽  
Troponin I ◽  
Cox Regression ◽  
Cox Regression Analysis ◽  
All Cause Mortality

Abstract Background CHA2DS2-VASc score has been used as a surrogate marker for predicting outcomes beyond thromboembolic risk in patients with atrial fibrillation (AF). Likewise, cardiac troponin I (cTnI) is a predictor of mortality in AF. Purpose This study aimed to investigate the association of cTnI and CHA2DS2-VASc score with long-term prognosis in patients admitted to the emergency department with AF. Methods A retrospective cohort study conducted between January 2012 and December 2013, enrolling patients admitted to the emergency department with AF and having documented cTnI measurements. CHA2DS2-VASc score was estimated. Primary endpoint was 5-year all-cause mortality, readmission for heart failure (HF), readmission for myocardial infarction (MI) and the composite end point of major adverse cardiac events defined as death, readmission for HF or readmission for MI (MACE). Results A total of 578 patients with AF were studied, of whom 252 patients had elevated levels of cTnI (43.6%) and 334 patients had CHA2DS2-VASc score >3 (57.8%). Patients with elevated cTnI tended to be oldercompared with those who did not have cTnI elevation and were more frequently comorbid and of higher ischemic risk, including hypertension, prior MI, prior HF, chronic renal failure and peripheral artery disease. The overall median CHA2DS2-VASc score was higher in those with cTnI elevation compared to those patients elevated cTnI levels (4.2 vs 3.3 points, p<0.001). Main diagnoses at hospital discharge were tachyarrhythmia 30.3%, followed by heart failure 17.7%, respiratory infections 9.5% and acute coronary syndrome 7.3%. At 5-year follow-up, all-cause death was significantly higher for patients with cTnI elevation compared with those who did not have cTnI elevation (56.4% vs. 27%; logrank test p<0.001). Specifically, for readmissions for HF and readmissions for MI there were no differences in between patients with or without cTnI elevation. In addition, MACE was reached in 165 patients (65.5%) with cTnI elevation, compare to 126 patients (38.7%) without cTnI elevation (p<0.001). On multivariable Cox regression analysis, cTnI elevation was an independent predictor of all-cause death (hazard ratio, 1.67, 95% confidence interval [CI]: 1.24–2.26, p=0.001) and of MACE (hazard ratio 1.47, 95% confidence interval 1.15–1.88; P=0.002), but it did not reach statistical significance for readmissions for MI and readmissions for HF. CHA2DS2-VASc score was a predictor on univariate Cox regression analysis for each endpoint, but it did not reach significance on multivariable Cox regression analysis for any endpoint. Conclusions cTnI is independently associated with long-term all-cause mortality in patients attending the emergency department with AF. cTnI compared to CHA2DS2-VASc score is thus a biomarker with predictive capacity for mortality in late follow-up, conferring utility in the risk stratification of patients with atrial fibrillation.

scholarly journals Evaluation of outcome relevance of quality indicators in the emergency department (ENQuIRE): study protocol for a prospective multicentre cohort study

BMJ Open ◽  
2020 ◽  
Vol 10 (9) ◽  
pp. e038776
Author(s):  
Susanne Drynda ◽  
Wencke Schindler ◽  
Anna Slagman ◽  
Johannes Pollmanns ◽  
Dirk Horenkamp-Sonntag ◽  
...  
Keyword(s):  
Emergency Department ◽  
Cohort Study ◽  
Quality Indicators ◽  
Patient Outcomes ◽  
Claims Data ◽  
Quality Measures ◽  
Patient Questionnaire ◽  
Multicentre Cohort Study ◽  
Multicentre Cohort

IntroductionQuality of emergency department (ED) care affects patient outcomes substantially. Quality indicators (QIs) for ED care are a major challenge due to the heterogeneity of patient populations, health care structures and processes in Germany. Although a number of quality measures are already in use, there is a paucity of data on the importance of these QIs on medium-term and long-term outcomes. The evaluation of outcome relevance of quality indicators in the emergency department study (ENQuIRE) aims to identify and investigate the relevance of QIs in the ED on patient outcomes in a 12-month follow-up.Methods and analysisThe study is a prospective non-interventional multicentre cohort study conducted in 15 EDs throughout Germany. Included are all patients in 2019, who were ≥18 years of age, insured at the Techniker Krankenkasse (statutory health insurance (SHI)) and gave their written informed consent to the study.The primary objective of the study is to assess the effect of selected quality measures on patient outcome. The data collected for this purpose comprise medical records from the ED treatment, discharge (claims) data from hospitalised patients, a patient questionnaire to be answered 6–8 weeks after emergency admission, and outcome measures in a 12-month follow-up obtained as claims data from the SHI.Descriptive and analytical statistics will be applied to provide summaries about the characteristics of QIs and associations between quality measures and patient outcomes.Ethics and disseminationApproval of the leading ethics committee at the Medical Faculty of the University of Magdeburg (reference number 163/18 from 19 November 2018) has been obtained and adapted by responsible local ethics committees.The findings of this work will be disseminated by publication of peer-reviewed manuscripts and presentations as conference contributions (abstracts, poster or oral presentations).Moreover, results will be discussed with clinical experts and medical associations before being proposed for implementation into the quality management of EDs.Trial registration numberGerman Clinical Trials Registry (DRKS00015203); Pre-results.

scholarly journals Despite Having Worse Risk Profiles, Northern Albertans Wait Longer for Specialist Follow-up After Emergency Department Visits for Atrial Fibrillation

CJC Open ◽  
2020 ◽  
Vol 2 (6) ◽  
pp. 610-618
Author(s):  
Brian H. Rowe ◽  
Finlay A. McAlister ◽  
Michelle M. Graham ◽  
Brian R. Holroyd ◽  
Rhonda J. Rosychuk
Keyword(s):  
Atrial Fibrillation ◽  
Emergency Department ◽  
Emergency Department Visits ◽  
Risk Profiles

Frequent Premature Atrial Contractions in Cryptogenic Stroke Predict Atrial Fibrillation Detection with Insertable Cardiac Monitoring

2020 ◽  
Vol 49 (2) ◽  
pp. 144-150 ◽  
Author(s):  
Kenichi Todo ◽  
Tomonori Iwata ◽  
Ryosuke Doijiri ◽  
Hiroshi Yamagami ◽  
Masafumi Morimoto ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
High Frequency ◽  
Strong Predictor ◽  
Cryptogenic Stroke ◽  
High Plasma ◽  
Cardiac Monitoring ◽  
Stroke Patients ◽  
Chads2 Score ◽  
Index Stroke

Objective: To determine whether frequent premature atrial contractions (PAC) predict atrial fibrillation (AF) in cryptogenic stroke patients, we analyzed the association between frequent PACs in 24-h Holter electrocardiogram recording and AF detected by insertable cardiac monitoring (ICM). Methods: We retrospectively analyzed a database of 66 consecutive patients with cryptogenic stroke who received ICM implantation between October 2016 and March 2018 at 5 stroke centers. We included the follow-up data until June 2018 in this analysis. We defined frequent PACs as the upper quartile of the 66 patients. We analyzed the association of frequent PACs with AF detected by ICM. Results: Frequent PACs were defined as >222 PACs per a 24-h period. The proportion of patients with newly detected AF by ICM was higher in patients with frequent PACs than those without (50% [8/16] vs. 22% [11/50], p < 0.05). Frequent PACs were associated with AF detection and time to the first AF after adjustment for CHADS2 score after index stroke, high plasma ­B-type natriuretic peptide (BNP; >100 pg/mL) or serum ­N-terminal pro-BNP levels (>300 pg/mL), and large left atrial diameter (≥45 mm). Conclusion: High frequency of PACs in cryptogenic stroke may be a strong predictor of AF detected by ICM.

P4139Prediction of atrial fibrillation in embolic stroke of unknown source

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
F T Range ◽  
D P Peters ◽  
T Zeus ◽  
S Jander ◽  
P Mueller ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Real Life ◽  
Patient Characteristics ◽  
Embolic Stroke ◽  
Baseline Heart Rate ◽  
Loop Recorder ◽  
Chads2 Score ◽  
Unknown Source ◽  
Significant Difference

Abstract Background Atrial fibrillation (AF) is one of the leading cardiogenic causes for embolic stroke of unknown source (ESUS). Its incidence is growing with patients' age. Detection and rule out of AF is complex and cumbersome. The best method is an implantable loop recorder (ILR). In patients elder than 60 years, incidence of AF is reported incongruently and reliable patient characteristics that can predict a low or high risk for AF are scarce. Purpose This study reports real life incidences of AF in a group of patients undergoing ILR after ESUS. It aims to depict age dependency of AF and to identify potential confounding factors. Methods In a single center study, we analysed 111 patients (age=62±13 years, nmale=65) who received an ILR in our centre following ESUS. Patient characteristics, brain imaging, hemodynamic monitoring, blood pressure, electrocardiography, holter ecg and echocardiography data from the initial hospital stay and ILR follow-up over a mean of 460 days were analysed. Primary endpoint was the recording of AF during follow-up. Results AF was detected in 23% of all patients. Patients with AF were significantly elder than those without AF (p=0.01). Incidence of AF was in Patients <60y: 14%, 60–69y: 13%, 70–79y: 45%, >80y: 67%. We observed a significant difference in AF incidence comparing patients younger and elder than 70 years (p=0.034). Both, CHADS-Vasc (p=0.036) and HATCH-scores (p=0.018) were higher in the AF group while the simple CHADS2 Score missed significance (p=0.068). PQ duration was longer in AF patients (p=0.022) and baseline heart rate at admission was lower (p=0.027). NIHSS scores were lower in the AF group at admission (2.97 vs. 4.10; p=0.049) but due to less neurological improvement in the AF group, this difference faded until dismission (1.09 vs 1.79 p=ns). Conclusions In our real life ILR group following ESUS, strongest predictor of AF was age. Pivot point rather was at 70 than at 60 years of age.

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