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Atrial fibrillation in emergency department: prevalence of sinus rhythm 1 week after discharge
  1. Camilla Fundarò1,
  2. Andrea Galli1,
  3. Stefano Paglia2,
  4. Silvia Colombo2,
  5. Angelo Rovellini3,
  6. Livio Colombo4,
  7. Valter Monzani3,
  8. Daniele Coen2,
  9. Stefano Guzzetti1
  1. 1Department of Emergency Medicine ‘Luigi Sacco’ Hospital, Milano, Italy
  2. 2Department of Emergency Medicine Ospedale Maggiore Niguarda, Milano, Italy
  3. 3Department of Emergency Medicine Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milano, Italy
  4. 4Department of Emergency Medicine Ospedale San Paolo, Milano, Italy
  1. Correspondence to Dr Stefano Guzzetti, Medicina di Urgenza, Via GB Grassi 74, Milano 20157, Italy; guzzetti.stefano{at}hsacco.it

Abstract

Background Current guidelines do not provide definitive indications about the treatment in emergency departments (ED) of patients with recent-onset atrial fibrillation (AF).

Methods A multicentre observational study involving four general hospitals of the same metropolitan area was conducted. All consecutive adult patients admitted to the ED with recent symptoms of AF (<48 h duration) and discharged home were considered. Patients who underwent ED early cardioversion were enrolled in group A. Patients managed with ventricular rate control were enrolled in group B.

Results On the 24 h Holter recordings at 1-week follow-up, stable sinus rhythm was detected in 46/58 (79.3%; 95% CI 68.9 to 89.7) patients in group A and 8/33 (24.2%; 95% CI 9.6 to 38.9) patients in group B (p<0.01).

Conclusion According to the study results, rhythm at the time of ED discharge is a poor indicator of the short-term evolution of AF.

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The optimal treatment for patients presenting to emergency departments (ED) with recent-onset atrial fibrillation (AF) is still an open issue. The two main published controlled studies demonstrated that rate control was not inferior to rhythm control for mortality and morbidity in patients with permanent AF.1 2 Analogous controlled studies in patients with recent-onset AF are lacking. Except for haemodynamically unstable patients, current guidelines do not provide definitive indications about the treatment in ED of patients with recent-onset AF.3 Consequently, the choice between rate and rhythm control in ED is largely an individual doctor's decision. Moreover, a high variability of prescription and duration of antithrombotic prophylaxis after ED discharge was reported,4 5 despite the clear indication of guidelines on this topic.3 We aimed to estimate the prevalence of sinus rhythm 1 week after discharge among patients presenting with acute AF.

Methods

A multicentre observational study was carried out involving the ED of four general hospitals of the same metropolitan area over a period of 6 months (December 2008 to May 2009). During this period all consecutive adult patients (aged 18–70 years) admitted to the ED with recent symptomatic AF (<48 h duration)6 were considered. Exclusion criteria were: (1) patients admitted to hospital; (2) no indication for rhythm control in accordance with the recommendations of international guidelines (mostly permanent AF); (3) haemodynamic instability (defined as systolic arterial pressure ≤90 mm Hg); (4) heart failure New York Heart Association (NYHA) class III–IV; (5) acute underlying medical or surgical cause of AF such as acute coronary syndrome; (6) cardiac pacemaker; (7) previous ablation of AF.

Among all the patients enrolled, those who underwent a cardioversion attempt and were discharged home in sinus rhythm were enrolled in group A. Patients who did not undergo a cardioversion attempt and were discharged in AF were enrolled in group B. Group B patients were managed with ventricular rate control if indicated and scheduled to undergo elective cardioversion. The investigators were not involved in the clinical decisions and the ED physicians were not informed of the study.

At the time of ED admission (enrolment), clinical history, physical examination, standard laboratory tests, rest ECG and chest x-ray were carried out. All patients considered in the analysis had outpatient medical examinations, rest ECG and 24-h Holter recording a week after enrolment (follow-up).

The study was approved by the institutional ethical review boards of the hospitals involved. All patients gave written informed consent. Data are presented as mean±SD or as percentages in the text and tables. The χ2 test and the Mann–Whitney U test were used to assess the difference between the two patient groups when appropriate. A two-sided p value of less than 0.05 was considered to be statistically significant.

Results

Overall 97 patients were enrolled in the study. Ninety-one patients had 24-h Holter of adequate quality at follow-up examination and were considered in the final analysis of data. Out of these 91 patients, 58 patients belonged to group A (cardioversion) and 33 patients to group B (no cardioversion). Three of the six patients not considered in the final analysis belonged to group A and three to group B. The main demographic and clinical characteristics of the two groups at the time of enrolment are summarised in table 1. The type of cardioversion performed in ED was electrical in 12/58 patients (20.6%), pharmacological in 43/58 patients (74.1%) and both (electrical and pharmacological) in three patients (5.2%) of group A. All patients in group A underwent at least one attempt of cardioversion in ED. Spontaneous recovery of sinus rhythm in ED was not observed. All patients included in group A were discharged home in sinus rhythm. All the patients included in group B were discharged home in AF rhythm. The percentage of cardioversion was not significantly different among the four hospitals involved in the study. The length of stay in ED was 7.9±8.3 h and 3.6±2.2 h in group A and group B, respectively (p<0.05).

Table 1

Main characteristics of patients at the time of enrolment

Antithrombotic prophylaxis

At ED discharge, in group A 18/58 (31.0%) patients had anticoagulant prophylaxis and 19/58 (32.7%) platelet inhibitors. Whereas in group B 29/33 (87.8%) and 3/33 (9%) patients had anticoagulant prophylaxis and platelet inhibitors, respectively. Overall, in patients discharged home after evaluation for recent-onset AF, anticoagulants were prescribed in 51.6% (47/91) and platelet inhibitors in 24.1% (22/91). The remaining 22 patients were discharged home without any antithrombotic prophylaxis. Antithrombotic prophylaxis was prescribed in accordance with the CHAD2 risk score.7

Follow-up

The duration of the follow-up period was 9.5±2.3 days in group A and 9.3±1.5 days in group B. The main clinical characteristics of the two groups at the time of follow-up are reported in table 2. On the follow-up ECG, sinus rhythm was present in 52/58 (89.6%; 95% CI 81.8 to 97.4) patients in group A and 13/33 (39.3%; 95% CI 22.7 to 56.1) in group B (p<0.001).

Table 2

Main characteristics of patients at the time of follow-up

On the 24 h Holter recordings at 1-week follow-up, stable sinus rhythm was detected in 46/58 (79.3%; 95% CI 68.9 to 89.7) patients in group A and 8/33 (24.2%; 95% CI 9.6 to 38.9) patients in group B (p<0.01); therefore 20.7% of group A patients and 24.2% of group B patients were in a different rhythm compared with the rhythm at ED discharge. Stable AF, defined as continuous AF rhythm during the recording time, was found in six (10.3%) patients of group A and in 16 (48.4%) patients of group B, whereas paroxysmal AF, defined as discontinuous AF rhythm during the recording time, was detected in six (10.3%) and nine (27.2%) patients of group A and group B, respectively. Considering the 24-h Holter recording results irrespective of ED treatment, stable sinus rhythm was present in 54/91 (59.3%) and stable or paroxysmal AF in 37/91 (40.6%) of the patients enrolled. These data are summarised in figure 1.

Figure 1

Percentage of stable sinus rhythm (white bar), stable atrial fibrillation (grey bar) and paroxysmal atrial fibrillation (black bar) in the two studied groups on ECG Holter recorded at 1-week follow-up.

Discussion

In haemodynamically stable patients presenting to ED with symptomatic AF the main concern is to establish if special efforts to obtain rhythm control should be mandatory, or if rate control may be considered a good alternative. Our results underline that a single ECG at the time of ED discharge was not a sufficiently good indicator for the efficacy of ED treatment of AF. These results enforce the recommendations of current guidelines about the prescription of antithrombotic prophylaxis in accordance with the CHAD2 risk score.3 7 The rhythm at the time of discharge should not be considered a good indicator for antithrombotic prophylaxis decisions.

Limitations

Our study does not add information about the advantages of choosing rate versus rhythm control in ED. We believe it gives useful hints to ED physicians to assess carefully the thromboembolic risk profile of all discharged patients.

References

View Abstract

Footnotes

  • Competing interests None.

  • Patient consent Obtained.

  • Ethics approval The study was approved by the Ethics Committees of the hospitals involved.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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