Original article 155
The epidemiology and management of recent-onset atrial fibrillation and flutter presenting to the Emergency Department Ailsa Hamiltona, Donna Clarkb, Alasdair Grayc, Aidan Cragga and Neill Grubbd; on behalf of the Emergency Medicine Research Group, Edinburgh (EMERGE) Objectives Atrial fibrillation (AF) and flutter are common tachyarrhythmias seen in the Emergency Department (ED). The management of recent-onset AF remains poorly defined. Two management strategies have been proposed: rhythm control versus rate control. The aims of this study were to investigate the epidemiology and management of recent-onset AF presenting to one large tertiary ED. Methods Retrospective analysis of ED records was carried out using the ED PAS database to identify eligible patients presenting between 1 July 2009 and 30 June 2011 with onset of AF in the previous 7 days. Patients were included for analysis if it was their first presentation, first diagnosis or a paroxysm of atrial fibrillation. Results A total of 494 patients (625 presentations) were analysed. AF (n = 564; 90.2%) and flutter (n = 61; 9.8%) were the presenting rhythms. In all, 374 (53.8%) presentations were paroxysmal atrial fibrillation. For patients with AF, rhythm control was attempted in 171 (55.0%) patients presenting less than 48 h after symptom onset. Pharmacotherapy was the approach in 105 (31.4%) patients, compared with direct current cardioversion (n = 45; 26.3%). Twenty-one patients received both. Flecainide (n = 85) and amiodarone (n = 33) were the main first-line pharmacotherapies, restoring sinus rhythm in 81.3 and 81.4% of patients, respectively. The overall efficacy of direct current cardioversion in restoring sinus rhythm was similar (78.8%). Eighty-one patients presented more than 48 h after
Background Atrial fibrillation (AF) is an abnormality of the heart rhythm that produces an irregular heartbeat. Its prevalence increases with age, from 0.5% at 50–59 years to 9% at 80–89 years with an overall prevalence of 1300/100 000 [1]. There is an associated increase in the risk of deaths (odds ratio 1.5 for men, 1.9 for women), especially shortly after diagnosis as a result of thromboembolic complications, such as stroke [2]. Recent-onset AF was responsible for 57 047 emergency admissions to the hospital in England during 2009–2010 [3]. Data suggest that 3–6% of emergency medical admissions in the UK have AF, about 40% newly diagnosed [4]. The direct cost of AF to the NHS was estimated to be £244 million in 2000 [5]. 0969-9546 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
symptom onset. Of those patients managed in the ED (n = 38; 71.7%) were managed with rate control. The majority of patients with atrial flutter presented less than 48 h after symptom onset (n = 48; 78.7%). Sixteen of these patients were managed with rhythm control strategies in the ED. Conclusion The epidemiology of recent-onset AF in this series is comparable with previous publications. Rhythm control was only attempted in approximately half of all eligible patients. There was no single-favoured management strategy. Our results mirror the literature in emphasizing the variation in management and the lack of robust evidence guiding the management of recent-onset AF and flutter. European Journal of Emergency Medicine 22:155–161 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. European Journal of Emergency Medicine 2015, 22:155–161 Keywords: atrial fibrillation, cardioversion, emergency department, management a Foundation Year 1 Doctor, NHS Lothian, bDepartment of Emergency Medicine, Southeast Scotland Training Scheme, Departments of cEmergency Medicine and d Cardiology, Royal Infirmary of Edinburgh, Edinburgh, UK
Correspondence to Alasdair Gray, Department of Emergency Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK Tel: + 0131 242 1338; fax: + 0131 242 1335; Received 2 December 2013 Accepted 16 July 2014
Patients with recent-onset AF commonly present to the Emergency Department (ED) because of distressing symptoms as a result of a rapid heart rate. If the onset is within 48 h, standard treatment involves drug therapy that converts the arrhythmia to sinus rhythm. The alternative is to provide rate control and anticoagulation that commits the patient to a minimum of 4 months of anticoagulation. For many patients, however, rate control does not adequately alleviate symptoms. Furthermore, it is recognized that AF can be self-sustaining because of electrical remodelling. This results in a reduction in successful cardioversion or ablation the longer the patient remains in AF. Rapid control of the heart rhythm is desirable to relieve disabling symptoms, reduce the risk of adverse events and reduce hospital length of stay or DOI: 10.1097/MEJ.0000000000000198
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156 European Journal of Emergency Medicine 2015, Vol 22 No 3
avoid the need for hospital admission altogether. The two most commonly used rhythm control agents in the UK practice are flecainide and amiodarone as recommended by the National Institute of Clinical Excellence in the UK and the European Society of Cardiology [6,7]. Any available data suggest a wide variability of clinical practice and poor adherence to professional guidance [8–10]. A recent international survey further supports this variation in practice between countries [11]. There is a paucity of European ED epidemiological data relating to this patient group and their early management. This study aims to investigate the epidemiology and ‘real life’ management of patients with recent-onset AF presenting to a UK ED.
when describing epidemiology and comorbidity but are reported separately for their ED management. The following data were recorded for these patients: routine demographics (age, sex), presentation characteristics, comorbidity, routine medications, acute treatments, ED cardioversion, presumptive diagnosis, admission, length of stay and outcome. The principal presenting complaint was noted for each episode, of which there were predefined six categories (see Table 1; the Results section). In episodes describing more than one of these, the most prominent or earliest symptom was reported. Data management and analysis
Setting
Data were managed and analysed in secure MS Excel 2003 (Microsoft Corporation, USA) databases held on the hospital-shared drive. Descriptive statistics were used to report key data.
A single tertiary academic adult UK ED (∼111 000 adult attendances in 2011).
Table 1
Research design
Patient characteristics (atrial fibrillation and flutter)
Characteristics
Design
A retrospective consecutive analysis, using health service records, of all patients presenting to the ED with AF or flutter was carried out between 1 July 2009 and 30 June 2011. ED electronic PAS records were searched using a sensitive key word free text search for the following words: atrial fibrillation OR atrial flutter OR atrial OR flutter OR cardioversion OR flecainide OR SVT or tachycardia. An initial report was generated of 9526 patients, including CHI (unique patient identifier) number, date of birth, date and time of presentation, mode of presentation, admission status and a copy of the episode electronic patient record. The full-hospital electronic patient record was reviewed including hospital inpatient discharge summaries, outpatient clinic letters and laboratory and radiology reports. This database was screened (by A.C., A.H. and D.C.) and all patients who did not have AF or flutter were excluded. Selection of patients for analysis
The remaining 2061 patients were categorized (by A.C., A.H. and D.C.) into the following groups by using all routinely available electronic hospital data into: recentonset AF or flutter (onset within 7 days, first diagnosis or paroxysm), persistent or permanent AF, secondary AF or flutter (clear precipitation by another illness, for example, infection), incidental finding (AF or flutter unrelated to current presentation – silent AF). In cases of uncertainty A.G. adjudicated in relation to the category of AF. A small number of patients (n = 15) remained unclassifiable. Only adult patients (18 years or older) who were categorized as having recent-onset AF or flutter were analysed. Patients were included if AF or flutter was demonstrated on the ambulance or ED ECG. Patients with atrial flutter were included with the AF patients
Age (n = 564) [mean (SD)] (years) First presentations PAF Range Men [n (%)] Initial rhythm [n (%)] Atrial fibrillation Atrial flutter Duration of arrhythmia (n = 564) [n (%)] < 48 h > 48 h Main presenting symptoms (n = 564) [n (%)] Palpitations Chest pain Dyspnoea Syncope Dizziness Other Initial vital signs [mean (SD)] Pulse rate (bpm) (n = 541) Systolic blood pressure (mmHg) (n = 462) CHA2DS2-VASc (range) Median Other medical history (n = 564) [n (%)] Ischaemic heart disease Valvular heart disease Hypertension Heart failure Previous congenital heart disease Stroke/TIA Diabetes Thyroid COPD Current medications (n = 564) [n (%)] Warfarin Aspirin Clopidogrel Dipyridamole Amiodarone Flecainide Verapamil Diltiazem Digoxin Metoprolol Bisoprolol
Presentations [n (%)] 68 223 (39.5) 341 (60.5) 20–97 307 (54.4) 564 (90.2) 61 (9.8) 531 (84.7) 94 (15.3) 298 128 40 36 27 35
(52.8) (22.7) (7.1) (6.4) (4.8) (6.2)
125 (32) 126 (23) 2 (0–7) 162 52 249 29 5 37 51 48 40
(28.7) (9.2) (44.1) (5.1) (0.9) (6.6) (9.0) (8.5) (7.1)
71 249 27 7 24 50 12 7 27 23 160
(12.6) (44.1) (4.8) (1.2) (4.3) (8.9) (2.1) (1.2) (4.8) (4.1) (28.4)
COPD, chronic obstructive pulmonary disease; PAF, paroxysmal atrial fibrillation; TIA, transient ischaemic attack.
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AF and flutter presenting to the ED Hamilton et al. 157
Ethics and research governance
The study was assessed by South East Scotland Research Ethics service. Data were managed in accordance with the Data Protection Act and Lothian Caldicott Guidelines.
Results A total of 625 episodes (494 patients) of recent-onset AF or atrial flutter were evaluated: 251 involving a first diagnosis of AF or flutter, and 374 episodes (244 patients) of paroxysmal atrial fibrillation or flutter. They had a mean age of 68 years (median 70 years; range 20–97 years). In 531 (84.7%) presentations the patient presented within 48 h of the onset of symptoms. Data were available on all patients for analyses. Attendance by emergency ambulance was the most common mode of referral (n = 260), followed by selfreferral (n = 180), NHS 24 referral (n = 65) and general practitioner referral (including out-of-hours primary care) (n = 87). Other pathways resulted in only a small number of presentations (n = 33). Comorbidity and routine medication
Patient characteristics including presenting symptoms, AF onset time, relevant past medical history and drugs, presenting physiological status and CHA2DS2-VASc scores [11] for each presentation are detailed in Table 1. Palpitations were the most common presenting symptom (n = 327; Table 1). Hypertension was the most frequently documented comorbidity (n = 249), closely followed by ischaemic heart disease (n = 186). Heart failure was recorded in 29 episodes on the basis of available past medical history data. The majority of patients were receiving routine anticoagulation or antiplatelet medication at presentation, with aspirin documented most frequently (n = 268). A large proportion of the episodes involved patients already using rhythm or rate control therapies, of which bisoprolol (n = 178) was the most common agent prescribed. Physiological and stroke assessment
Heart rate was recorded in 600 episodes (96% variable completion). The mean (SD) heart rate was 125 (33). Systolic blood pressure (SBP) was recorded less frequently (n = 513) with a completion rate of 82.1%. In all, 483 episodes presented with an SBP greater than 90 mmHg. Only 30 patients had a recorded SBP of less than 90 mmHg. On the basis of European Resuscitation Guidelines, 143 patients met one or more criteria for haemodynamic instability [12]. The median CHA2DS2-VASc score, a clinical prediction tool used to calculate the risk of stroke for patients in AF, was 2 (range 0–7). Emergency Department management
In all, 404 (n = 625; 64.6%) of the episodes received documented active management in the ED. Of those presenting in AF, 346 (n = 442; 78.3% still in arrhythmia
after assessment) were actively managed in the ED. Active management included direct current cardioversion (DCC), any pharmacotherapy and supportive treatment, for example, intravenous fluids. A total of 483 AF patients presented less than 48 h of symptom onset with 112 (23.2%) patients cardioverting spontaneously either en route to the ED or while awaiting completion of clinical assessment. Therefore, a total of 371 patients were eligible for active management in the ED, of which 301 (81.1%) patients were actively managed. The majority (n = 171; 56.4%) received either electrical (n = 45) or pharmacological (n = 105) cardioversion. A minority of patients (n = 21) received both strategies in the ED (Fig. 1). For those patients requiring procedural sedation and analgesia, this was delivered by emergency physicians according to a departmental standard operating procedure. Flecainide and amiodarone were the most commonly used pharmacological cardioversion strategies. The number of successful cardioversions, electrical, pharmacological and combination therapy are highlighted in Table 2. A total of 124 patients were administered rate control agents only. The most popular intravenous and oral preparations were metoprolol (n = 50) and digoxin (n = 35), respectively. A total of 61 (9.8%) presentations with atrial flutter were reported. In all, 48 episodes presented less than 48 h after the onset of symptoms, with six patients cardioverting spontaneously. The majority (n = 32; 76.1%) were actively managed. Eight (25%) patients were cardioverted using DCC. Adenosine was used as a single agent in five (15.6%) presentations, and in combination with DCC on two occasions. It was unclear from the ED documentation whether adenosine was used for diagnostic or therapeutic reasons. Flecainide and amiodarone were used in eight further presentations (n = 3 and 5, respectively). Thirteen patients presented with atrial flutter more than 48 h after symptom onset. Seven patients were managed with rate control strategies. A total of 81 episodes of AF presented more than 48 h after the onset of symptoms. Ten episodes spontaneously converted to sinus rhythm while awaiting review in the ED. Fifty-three patients were actively managed, with the majority (n = 37; 69.8%) remaining in AF (Fig. 2). Only seven (13.2%) of these episodes received a rhythm control strategy, with amiodarone being used in four episodes, flecainide in two episodes and magnesium in the other. In the remaining 46 episodes, 28 received oral rate control agents, nine intravenous preparations and one both oral and intravenous. Excluding the 112 AF patients who spontaneously cardioverted, 371 AF patients presented less than 48 h from onset and were suitable for active management with their discharge rhythms highlighted in Table 2. In all, 231 (64.2%) ED cardioverted patients were admitted to
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Fig. 1 Patients presenting in AF 48 h) Disposition from ED (n = 625) Admitted to ward Discharged home Cardiology input in ED (n = 625) Cardiology outpatient referral after discharge (n = 625)
Presentations [n (%)] 483 112
248 (66.8)
63 (17.0) 60 (16.1)
3 h 32 min (interquartile range 2 h 50 min–3 h 54 min) 3 h 31 min 3 h 40 min 4 h 5 min 3 h 51 min 3 h 52 min 3 h 15 min 3 h 33 min 418 207 281 336
(66.9) (33.1) (45.0) (53.8)
AF, atrial fibrillation; DCC, direct current cardioversion; ED, Emergency Department.
and emergency management of recent-onset AF and flutter. Approximately 60% of episodes presenting to the ED were paroxysmal atrial fibrillation, with the remaining third a first diagnosis, consistent with previous literature [8,13,14]. Flecainide was the preferred first-line therapy in our centre for those patients with onset time less than 48 h. Amiodarone was the other agent regularly used in our patient cohort. We found the ED cardioversion success rates to be similar; 81.2% for flecainide and 81.8% for amiodarone, when used as first-line agents. The reason for our higher cardioversion rate with pharmacotherapy is unclear. Comparative studies have not demonstrated any significant superiority of flecainide over amiodarone in restoring sinus rhythm. However, flecainide is thought to be faster in restoring sinus rhythm [8,15] with some studies suggesting a success rate between 59 and 92% within 2 h. The success of cardioversion seems to be dependent on the time from AF onset to drug administration [15]. Flecainide, in our study was administered as an intravenous bolus of 2 mg/kg over 20 min [16]. Flecainide can also be given orally with success rates from studies being between 59 and 95% within 3–8 h [17]. There are a number of different dosage regimes for amiodarone. In our population amiodarone was administered as an intravenous infusion of 300 mg over 10–60 min followed by a further 900 mg if required as an infusion over 24 h. A recent study by Rogenstein et al. [11] highlighted not only the variation in management practices, but also the variation in choice of agents with
Canada preferring procainamide, and North America, Australasia and the UK preferring amiodarone, with flecainide the preferred first-line agent in our study. The evidence and guidance to support the optimal management of recent-onset AF or flutter in the ED is limited and is largely based on expert consensus [6,7,18]. Clinical guidelines recommend cardioversion if the onset is within 48 h. The alternative, if symptoms continue for more than 48 h, is to provide rate control and anticoagulation [18]. For those presenting less than 48 h after the onset of symptoms, pharmacotherapy is the preferred cardioversion strategy [18] unless the ERC criteria for haemodynamic instability are present [19,20]. In our population presenting AF, a total of 371 presentations were eligible for cardioversion, with 311 episodes actively managed in our ED. However, only 171 (55.0%) of those eligible for cardioversion strategies received an intervention in an attempt to cardiovert to sinus rhythm. This is consistent with other reported literature [6,19]. The GEFAUR-1 study reported that 42% of all eligible patients (< 48 h) received rhythm control therapy [16]. Stiell et al. [8] investigated management strategies of acute AF at Canadian centres and found that 59.4% of eligible patients received cardioversion strategies. Recent Canadian data describe a similar approach to ours, albeit they recommend a longer observation period than is possible in many UK ED departments, to prevent unnecessary hospital admissions [20]. It is unclear why guidelines are inconsistently followed. It is likely to reflect the substantial lack of high-quality evidence to support clinical decisions. Moreover, the ED management of recent-onset AF is complex, in particular, in balancing the potential benefits of aggressive cardioversion strategies with the potential risk of harm. There are anecdotal concerns regarding drug side-effect profiles, especially the negative inotropic and proarrhythmic effects of cardioverting agents and the agents used during procedural sedation and analgesia if utilizing an electrical cardioversion strategy. AF can occur as a result of noncardiac disease such as infection and electrolyte balance, and delineating such secondary causes contributes to the difficulty in decision-making and the lack of adoption of a rhythm control strategy. Although we explicitly excluded, before analysis, any patient without a clear AF onset time, it may be that in some cases rhythm control was not pursued because of clinician uncertainty regarding this time. Furthermore, clinicians are concerned with regard to the risk of thromboembolic complications when cardioverting AF without anticoagulation. Weigner et al. [21] measured the embolic incidence at 30 days after cardioversion in 357 patients who presented with symptoms of AF lasting less than 48 h. Three patients suffered embolic events, similar to other studies of ED patients cardioverted without anticoagulation [22]. As we reported, a significant proportion of patients cardiovert spontaneously while awaiting assessment and management in
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the ED. Vinson et al. [22] reported spontaneous cardioverting in 28.6% of patients, which was higher than 20.5% of patients who cardioverted spontaneously in our study. However, this differs markedly from the 66.7% of patients in the study of Weigner and colleagues. This results in some clinicians adopting a wait-and-see policy if the patient is physiologically stable or providing rate control only. These factors all contribute to the complexity of decision-making, ultimately leading to variation in practice as seen in these and other previously reported data [6,8,13]. Finally, patient preference may impact upon management decisions around electrical versus pharmacological cardioversion, rhythm versus rate control or the adoption of a wait-and-review policy. Early consistent management of this important and common condition is urgently needed. The benefits of early cardioversion in terms of symptom control and the potential for admission avoidance need to be emphasized by both professional organizations and senior clinicians. DCC is highly effective in restoring sinus rhythm [22]. Furthermore, it is associated with fewer adverse events compared with pharmacological cardioversion strategies [23]. However, there is currently no consensus on its use in ED or the best approach to adjuvant pharmacotherapy. Our study demonstrated similar efficacy of DCC compared with pharmacotherapy (78.4 vs. 81.4%). Del Arco et al. reported a similar success rate with DCC to our study, but a lower success rate with pharmacotherapy [16]. Despite the high success rate and relatively low complications, its use as a first-line strategy in our ED remained less than pharmacotherapy (127 vs. 61 episodes). This may be explained by the need for procedural sedation and analgesia and potential constraints around fasting times. In addition, the absence of clear guidance and protocols on its use may hinder its uptake. Furthermore, we demonstrated that restoration of sinus rhythm was more efficacious in those ultimately managed with a combination of DCC and pharmacotherapy (91.3%), similar to a study by Stiell et al. [24] using a combination of procainamide and DCC. More focused guidance on the use of both entities may increase the efficacy of restoring sinus rhythm in patients with and without structural heart disease. For those patients presenting more than 48 h and eligible for rate control therapy, the majority of episodes were actively managed in the ED. Of these, 79% of presentations received rate control strategies. In our ED, it appeared that physicians were more likely to adhere to guidelines in those presenting more than 48 h; it is unclear why this may be the case. Many studies looking at the management of recent-onset AF do not report the management strategies for patients presenting more than 48 h [8,16]. Several potential limitations of our study should be acknowledged. This study focused on one tertiary ED
and may not be representative of the wider management of recent-onset AF and flutter. This was a retrospective analysis of ED records and as such some cases may have been missed, or incomplete data sets encountered. We do not, however, believe that these issues substantially limit the validity of these data. Recent-onset AF and flutter are variably managed in this large single-centre study. The management of those presenting more than 48 h after the onset of symptoms is, in general, compliant with current professional guidelines. The management of those presenting less than 48 h after the onset of symptoms is variable, with less than half (45.5%) of potential eligible patients being managed in the ED by cardioversion strategies. It is unclear why clinicians are not compliant with national or professional recommendations. We believe that devising a uniform strategy for the management of recent-onset AF, particularly those eligible for electrical or pharmacological cardioversion, may ameliorate the currently complex strategies and ultimately improve patient care. Further research is required to better determine the reluctance to comply with current professional guidance and to investigate methods to support early diagnostic and therapeutic decision-making for this common ED arrhythmia. This will ultimately support the consistent delivery of safe and evidence-based practice.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
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The epidemiology and management of recent-onset atrial fibrillation and flutter presenting to the Emergency Department Ailsa Hamiltona, Donna Clarkb, Alasdair Grayc, Aidan Cragga and Neill Grubbd; on behalf of the Emergency Medicine Research Group, Edinburgh (EMERGE) Objectives Atrial fibrillation (AF) and flutter are common tachyarrhythmias seen in the Emergency Department (ED). The management of recent-onset AF remains poorly defined. Two management strategies have been proposed: rhythm control versus rate control. The aims of this study were to investigate the epidemiology and management of recent-onset AF presenting to one large tertiary ED. Methods Retrospective analysis of ED records was carried out using the ED PAS database to identify eligible patients presenting between 1 July 2009 and 30 June 2011 with onset of AF in the previous 7 days. Patients were included for analysis if it was their first presentation, first diagnosis or a paroxysm of atrial fibrillation. Results A total of 494 patients (625 presentations) were analysed. AF (n = 564; 90.2%) and flutter (n = 61; 9.8%) were the presenting rhythms. In all, 374 (53.8%) presentations were paroxysmal atrial fibrillation. For patients with AF, rhythm control was attempted in 171 (55.0%) patients presenting less than 48 h after symptom onset. Pharmacotherapy was the approach in 105 (31.4%) patients, compared with direct current cardioversion (n = 45; 26.3%). Twenty-one patients received both. Flecainide (n = 85) and amiodarone (n = 33) were the main first-line pharmacotherapies, restoring sinus rhythm in 81.3 and 81.4% of patients, respectively. The overall efficacy of direct current cardioversion in restoring sinus rhythm was similar (78.8%). Eighty-one patients presented more than 48 h after
Background Atrial fibrillation (AF) is an abnormality of the heart rhythm that produces an irregular heartbeat. Its prevalence increases with age, from 0.5% at 50–59 years to 9% at 80–89 years with an overall prevalence of 1300/100 000 [1]. There is an associated increase in the risk of deaths (odds ratio 1.5 for men, 1.9 for women), especially shortly after diagnosis as a result of thromboembolic complications, such as stroke [2]. Recent-onset AF was responsible for 57 047 emergency admissions to the hospital in England during 2009–2010 [3]. Data suggest that 3–6% of emergency medical admissions in the UK have AF, about 40% newly diagnosed [4]. The direct cost of AF to the NHS was estimated to be £244 million in 2000 [5]. 0969-9546 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
symptom onset. Of those patients managed in the ED (n = 38; 71.7%) were managed with rate control. The majority of patients with atrial flutter presented less than 48 h after symptom onset (n = 48; 78.7%). Sixteen of these patients were managed with rhythm control strategies in the ED. Conclusion The epidemiology of recent-onset AF in this series is comparable with previous publications. Rhythm control was only attempted in approximately half of all eligible patients. There was no single-favoured management strategy. Our results mirror the literature in emphasizing the variation in management and the lack of robust evidence guiding the management of recent-onset AF and flutter. European Journal of Emergency Medicine 22:155–161 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. European Journal of Emergency Medicine 2015, 22:155–161 Keywords: atrial fibrillation, cardioversion, emergency department, management a Foundation Year 1 Doctor, NHS Lothian, bDepartment of Emergency Medicine, Southeast Scotland Training Scheme, Departments of cEmergency Medicine and d Cardiology, Royal Infirmary of Edinburgh, Edinburgh, UK
Correspondence to Alasdair Gray, Department of Emergency Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK Tel: + 0131 242 1338; fax: + 0131 242 1335; Received 2 December 2013 Accepted 16 July 2014
Patients with recent-onset AF commonly present to the Emergency Department (ED) because of distressing symptoms as a result of a rapid heart rate. If the onset is within 48 h, standard treatment involves drug therapy that converts the arrhythmia to sinus rhythm. The alternative is to provide rate control and anticoagulation that commits the patient to a minimum of 4 months of anticoagulation. For many patients, however, rate control does not adequately alleviate symptoms. Furthermore, it is recognized that AF can be self-sustaining because of electrical remodelling. This results in a reduction in successful cardioversion or ablation the longer the patient remains in AF. Rapid control of the heart rhythm is desirable to relieve disabling symptoms, reduce the risk of adverse events and reduce hospital length of stay or DOI: 10.1097/MEJ.0000000000000198
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156 European Journal of Emergency Medicine 2015, Vol 22 No 3
avoid the need for hospital admission altogether. The two most commonly used rhythm control agents in the UK practice are flecainide and amiodarone as recommended by the National Institute of Clinical Excellence in the UK and the European Society of Cardiology [6,7]. Any available data suggest a wide variability of clinical practice and poor adherence to professional guidance [8–10]. A recent international survey further supports this variation in practice between countries [11]. There is a paucity of European ED epidemiological data relating to this patient group and their early management. This study aims to investigate the epidemiology and ‘real life’ management of patients with recent-onset AF presenting to a UK ED.
when describing epidemiology and comorbidity but are reported separately for their ED management. The following data were recorded for these patients: routine demographics (age, sex), presentation characteristics, comorbidity, routine medications, acute treatments, ED cardioversion, presumptive diagnosis, admission, length of stay and outcome. The principal presenting complaint was noted for each episode, of which there were predefined six categories (see Table 1; the Results section). In episodes describing more than one of these, the most prominent or earliest symptom was reported. Data management and analysis
Setting
Data were managed and analysed in secure MS Excel 2003 (Microsoft Corporation, USA) databases held on the hospital-shared drive. Descriptive statistics were used to report key data.
A single tertiary academic adult UK ED (∼111 000 adult attendances in 2011).
Table 1
Research design
Patient characteristics (atrial fibrillation and flutter)
Characteristics
Design
A retrospective consecutive analysis, using health service records, of all patients presenting to the ED with AF or flutter was carried out between 1 July 2009 and 30 June 2011. ED electronic PAS records were searched using a sensitive key word free text search for the following words: atrial fibrillation OR atrial flutter OR atrial OR flutter OR cardioversion OR flecainide OR SVT or tachycardia. An initial report was generated of 9526 patients, including CHI (unique patient identifier) number, date of birth, date and time of presentation, mode of presentation, admission status and a copy of the episode electronic patient record. The full-hospital electronic patient record was reviewed including hospital inpatient discharge summaries, outpatient clinic letters and laboratory and radiology reports. This database was screened (by A.C., A.H. and D.C.) and all patients who did not have AF or flutter were excluded. Selection of patients for analysis
The remaining 2061 patients were categorized (by A.C., A.H. and D.C.) into the following groups by using all routinely available electronic hospital data into: recentonset AF or flutter (onset within 7 days, first diagnosis or paroxysm), persistent or permanent AF, secondary AF or flutter (clear precipitation by another illness, for example, infection), incidental finding (AF or flutter unrelated to current presentation – silent AF). In cases of uncertainty A.G. adjudicated in relation to the category of AF. A small number of patients (n = 15) remained unclassifiable. Only adult patients (18 years or older) who were categorized as having recent-onset AF or flutter were analysed. Patients were included if AF or flutter was demonstrated on the ambulance or ED ECG. Patients with atrial flutter were included with the AF patients
Age (n = 564) [mean (SD)] (years) First presentations PAF Range Men [n (%)] Initial rhythm [n (%)] Atrial fibrillation Atrial flutter Duration of arrhythmia (n = 564) [n (%)] < 48 h > 48 h Main presenting symptoms (n = 564) [n (%)] Palpitations Chest pain Dyspnoea Syncope Dizziness Other Initial vital signs [mean (SD)] Pulse rate (bpm) (n = 541) Systolic blood pressure (mmHg) (n = 462) CHA2DS2-VASc (range) Median Other medical history (n = 564) [n (%)] Ischaemic heart disease Valvular heart disease Hypertension Heart failure Previous congenital heart disease Stroke/TIA Diabetes Thyroid COPD Current medications (n = 564) [n (%)] Warfarin Aspirin Clopidogrel Dipyridamole Amiodarone Flecainide Verapamil Diltiazem Digoxin Metoprolol Bisoprolol
Presentations [n (%)] 68 223 (39.5) 341 (60.5) 20–97 307 (54.4) 564 (90.2) 61 (9.8) 531 (84.7) 94 (15.3) 298 128 40 36 27 35
(52.8) (22.7) (7.1) (6.4) (4.8) (6.2)
125 (32) 126 (23) 2 (0–7) 162 52 249 29 5 37 51 48 40
(28.7) (9.2) (44.1) (5.1) (0.9) (6.6) (9.0) (8.5) (7.1)
71 249 27 7 24 50 12 7 27 23 160
(12.6) (44.1) (4.8) (1.2) (4.3) (8.9) (2.1) (1.2) (4.8) (4.1) (28.4)
COPD, chronic obstructive pulmonary disease; PAF, paroxysmal atrial fibrillation; TIA, transient ischaemic attack.
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AF and flutter presenting to the ED Hamilton et al. 157
Ethics and research governance
The study was assessed by South East Scotland Research Ethics service. Data were managed in accordance with the Data Protection Act and Lothian Caldicott Guidelines.
Results A total of 625 episodes (494 patients) of recent-onset AF or atrial flutter were evaluated: 251 involving a first diagnosis of AF or flutter, and 374 episodes (244 patients) of paroxysmal atrial fibrillation or flutter. They had a mean age of 68 years (median 70 years; range 20–97 years). In 531 (84.7%) presentations the patient presented within 48 h of the onset of symptoms. Data were available on all patients for analyses. Attendance by emergency ambulance was the most common mode of referral (n = 260), followed by selfreferral (n = 180), NHS 24 referral (n = 65) and general practitioner referral (including out-of-hours primary care) (n = 87). Other pathways resulted in only a small number of presentations (n = 33). Comorbidity and routine medication
Patient characteristics including presenting symptoms, AF onset time, relevant past medical history and drugs, presenting physiological status and CHA2DS2-VASc scores [11] for each presentation are detailed in Table 1. Palpitations were the most common presenting symptom (n = 327; Table 1). Hypertension was the most frequently documented comorbidity (n = 249), closely followed by ischaemic heart disease (n = 186). Heart failure was recorded in 29 episodes on the basis of available past medical history data. The majority of patients were receiving routine anticoagulation or antiplatelet medication at presentation, with aspirin documented most frequently (n = 268). A large proportion of the episodes involved patients already using rhythm or rate control therapies, of which bisoprolol (n = 178) was the most common agent prescribed. Physiological and stroke assessment
Heart rate was recorded in 600 episodes (96% variable completion). The mean (SD) heart rate was 125 (33). Systolic blood pressure (SBP) was recorded less frequently (n = 513) with a completion rate of 82.1%. In all, 483 episodes presented with an SBP greater than 90 mmHg. Only 30 patients had a recorded SBP of less than 90 mmHg. On the basis of European Resuscitation Guidelines, 143 patients met one or more criteria for haemodynamic instability [12]. The median CHA2DS2-VASc score, a clinical prediction tool used to calculate the risk of stroke for patients in AF, was 2 (range 0–7). Emergency Department management
In all, 404 (n = 625; 64.6%) of the episodes received documented active management in the ED. Of those presenting in AF, 346 (n = 442; 78.3% still in arrhythmia
after assessment) were actively managed in the ED. Active management included direct current cardioversion (DCC), any pharmacotherapy and supportive treatment, for example, intravenous fluids. A total of 483 AF patients presented less than 48 h of symptom onset with 112 (23.2%) patients cardioverting spontaneously either en route to the ED or while awaiting completion of clinical assessment. Therefore, a total of 371 patients were eligible for active management in the ED, of which 301 (81.1%) patients were actively managed. The majority (n = 171; 56.4%) received either electrical (n = 45) or pharmacological (n = 105) cardioversion. A minority of patients (n = 21) received both strategies in the ED (Fig. 1). For those patients requiring procedural sedation and analgesia, this was delivered by emergency physicians according to a departmental standard operating procedure. Flecainide and amiodarone were the most commonly used pharmacological cardioversion strategies. The number of successful cardioversions, electrical, pharmacological and combination therapy are highlighted in Table 2. A total of 124 patients were administered rate control agents only. The most popular intravenous and oral preparations were metoprolol (n = 50) and digoxin (n = 35), respectively. A total of 61 (9.8%) presentations with atrial flutter were reported. In all, 48 episodes presented less than 48 h after the onset of symptoms, with six patients cardioverting spontaneously. The majority (n = 32; 76.1%) were actively managed. Eight (25%) patients were cardioverted using DCC. Adenosine was used as a single agent in five (15.6%) presentations, and in combination with DCC on two occasions. It was unclear from the ED documentation whether adenosine was used for diagnostic or therapeutic reasons. Flecainide and amiodarone were used in eight further presentations (n = 3 and 5, respectively). Thirteen patients presented with atrial flutter more than 48 h after symptom onset. Seven patients were managed with rate control strategies. A total of 81 episodes of AF presented more than 48 h after the onset of symptoms. Ten episodes spontaneously converted to sinus rhythm while awaiting review in the ED. Fifty-three patients were actively managed, with the majority (n = 37; 69.8%) remaining in AF (Fig. 2). Only seven (13.2%) of these episodes received a rhythm control strategy, with amiodarone being used in four episodes, flecainide in two episodes and magnesium in the other. In the remaining 46 episodes, 28 received oral rate control agents, nine intravenous preparations and one both oral and intravenous. Excluding the 112 AF patients who spontaneously cardioverted, 371 AF patients presented less than 48 h from onset and were suitable for active management with their discharge rhythms highlighted in Table 2. In all, 231 (64.2%) ED cardioverted patients were admitted to
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158 European Journal of Emergency Medicine 2015, Vol 22 No 3
Fig. 1 Patients presenting in AF 48 h) Disposition from ED (n = 625) Admitted to ward Discharged home Cardiology input in ED (n = 625) Cardiology outpatient referral after discharge (n = 625)
Presentations [n (%)] 483 112
248 (66.8)
63 (17.0) 60 (16.1)
3 h 32 min (interquartile range 2 h 50 min–3 h 54 min) 3 h 31 min 3 h 40 min 4 h 5 min 3 h 51 min 3 h 52 min 3 h 15 min 3 h 33 min 418 207 281 336
(66.9) (33.1) (45.0) (53.8)
AF, atrial fibrillation; DCC, direct current cardioversion; ED, Emergency Department.
and emergency management of recent-onset AF and flutter. Approximately 60% of episodes presenting to the ED were paroxysmal atrial fibrillation, with the remaining third a first diagnosis, consistent with previous literature [8,13,14]. Flecainide was the preferred first-line therapy in our centre for those patients with onset time less than 48 h. Amiodarone was the other agent regularly used in our patient cohort. We found the ED cardioversion success rates to be similar; 81.2% for flecainide and 81.8% for amiodarone, when used as first-line agents. The reason for our higher cardioversion rate with pharmacotherapy is unclear. Comparative studies have not demonstrated any significant superiority of flecainide over amiodarone in restoring sinus rhythm. However, flecainide is thought to be faster in restoring sinus rhythm [8,15] with some studies suggesting a success rate between 59 and 92% within 2 h. The success of cardioversion seems to be dependent on the time from AF onset to drug administration [15]. Flecainide, in our study was administered as an intravenous bolus of 2 mg/kg over 20 min [16]. Flecainide can also be given orally with success rates from studies being between 59 and 95% within 3–8 h [17]. There are a number of different dosage regimes for amiodarone. In our population amiodarone was administered as an intravenous infusion of 300 mg over 10–60 min followed by a further 900 mg if required as an infusion over 24 h. A recent study by Rogenstein et al. [11] highlighted not only the variation in management practices, but also the variation in choice of agents with
Canada preferring procainamide, and North America, Australasia and the UK preferring amiodarone, with flecainide the preferred first-line agent in our study. The evidence and guidance to support the optimal management of recent-onset AF or flutter in the ED is limited and is largely based on expert consensus [6,7,18]. Clinical guidelines recommend cardioversion if the onset is within 48 h. The alternative, if symptoms continue for more than 48 h, is to provide rate control and anticoagulation [18]. For those presenting less than 48 h after the onset of symptoms, pharmacotherapy is the preferred cardioversion strategy [18] unless the ERC criteria for haemodynamic instability are present [19,20]. In our population presenting AF, a total of 371 presentations were eligible for cardioversion, with 311 episodes actively managed in our ED. However, only 171 (55.0%) of those eligible for cardioversion strategies received an intervention in an attempt to cardiovert to sinus rhythm. This is consistent with other reported literature [6,19]. The GEFAUR-1 study reported that 42% of all eligible patients (< 48 h) received rhythm control therapy [16]. Stiell et al. [8] investigated management strategies of acute AF at Canadian centres and found that 59.4% of eligible patients received cardioversion strategies. Recent Canadian data describe a similar approach to ours, albeit they recommend a longer observation period than is possible in many UK ED departments, to prevent unnecessary hospital admissions [20]. It is unclear why guidelines are inconsistently followed. It is likely to reflect the substantial lack of high-quality evidence to support clinical decisions. Moreover, the ED management of recent-onset AF is complex, in particular, in balancing the potential benefits of aggressive cardioversion strategies with the potential risk of harm. There are anecdotal concerns regarding drug side-effect profiles, especially the negative inotropic and proarrhythmic effects of cardioverting agents and the agents used during procedural sedation and analgesia if utilizing an electrical cardioversion strategy. AF can occur as a result of noncardiac disease such as infection and electrolyte balance, and delineating such secondary causes contributes to the difficulty in decision-making and the lack of adoption of a rhythm control strategy. Although we explicitly excluded, before analysis, any patient without a clear AF onset time, it may be that in some cases rhythm control was not pursued because of clinician uncertainty regarding this time. Furthermore, clinicians are concerned with regard to the risk of thromboembolic complications when cardioverting AF without anticoagulation. Weigner et al. [21] measured the embolic incidence at 30 days after cardioversion in 357 patients who presented with symptoms of AF lasting less than 48 h. Three patients suffered embolic events, similar to other studies of ED patients cardioverted without anticoagulation [22]. As we reported, a significant proportion of patients cardiovert spontaneously while awaiting assessment and management in
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160 European Journal of Emergency Medicine 2015, Vol 22 No 3
the ED. Vinson et al. [22] reported spontaneous cardioverting in 28.6% of patients, which was higher than 20.5% of patients who cardioverted spontaneously in our study. However, this differs markedly from the 66.7% of patients in the study of Weigner and colleagues. This results in some clinicians adopting a wait-and-see policy if the patient is physiologically stable or providing rate control only. These factors all contribute to the complexity of decision-making, ultimately leading to variation in practice as seen in these and other previously reported data [6,8,13]. Finally, patient preference may impact upon management decisions around electrical versus pharmacological cardioversion, rhythm versus rate control or the adoption of a wait-and-review policy. Early consistent management of this important and common condition is urgently needed. The benefits of early cardioversion in terms of symptom control and the potential for admission avoidance need to be emphasized by both professional organizations and senior clinicians. DCC is highly effective in restoring sinus rhythm [22]. Furthermore, it is associated with fewer adverse events compared with pharmacological cardioversion strategies [23]. However, there is currently no consensus on its use in ED or the best approach to adjuvant pharmacotherapy. Our study demonstrated similar efficacy of DCC compared with pharmacotherapy (78.4 vs. 81.4%). Del Arco et al. reported a similar success rate with DCC to our study, but a lower success rate with pharmacotherapy [16]. Despite the high success rate and relatively low complications, its use as a first-line strategy in our ED remained less than pharmacotherapy (127 vs. 61 episodes). This may be explained by the need for procedural sedation and analgesia and potential constraints around fasting times. In addition, the absence of clear guidance and protocols on its use may hinder its uptake. Furthermore, we demonstrated that restoration of sinus rhythm was more efficacious in those ultimately managed with a combination of DCC and pharmacotherapy (91.3%), similar to a study by Stiell et al. [24] using a combination of procainamide and DCC. More focused guidance on the use of both entities may increase the efficacy of restoring sinus rhythm in patients with and without structural heart disease. For those patients presenting more than 48 h and eligible for rate control therapy, the majority of episodes were actively managed in the ED. Of these, 79% of presentations received rate control strategies. In our ED, it appeared that physicians were more likely to adhere to guidelines in those presenting more than 48 h; it is unclear why this may be the case. Many studies looking at the management of recent-onset AF do not report the management strategies for patients presenting more than 48 h [8,16]. Several potential limitations of our study should be acknowledged. This study focused on one tertiary ED
and may not be representative of the wider management of recent-onset AF and flutter. This was a retrospective analysis of ED records and as such some cases may have been missed, or incomplete data sets encountered. We do not, however, believe that these issues substantially limit the validity of these data. Recent-onset AF and flutter are variably managed in this large single-centre study. The management of those presenting more than 48 h after the onset of symptoms is, in general, compliant with current professional guidelines. The management of those presenting less than 48 h after the onset of symptoms is variable, with less than half (45.5%) of potential eligible patients being managed in the ED by cardioversion strategies. It is unclear why clinicians are not compliant with national or professional recommendations. We believe that devising a uniform strategy for the management of recent-onset AF, particularly those eligible for electrical or pharmacological cardioversion, may ameliorate the currently complex strategies and ultimately improve patient care. Further research is required to better determine the reluctance to comply with current professional guidance and to investigate methods to support early diagnostic and therapeutic decision-making for this common ED arrhythmia. This will ultimately support the consistent delivery of safe and evidence-based practice.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
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