P127: A prospective study of the management and outcomes of patients with symptomatic atrial fibrillation and/or flutter presenting to emergency departments

Abstract

Introduction: Patients with new onset and chronic atrial fibrillation and/or flutter (AFF) present to emergency departments (ED) with symptoms requiring acute management decisions. Most research has focused on patients with acute (<48 hours and/or <7 days with adequate anticoagulation) presentations of AFF and for whom rhythm control is considered safe. This study explored the demographic characteristics, risk factors, anticoagulant/anti-platelet prescription, and outcomes for patients with symptomatic AFF. Methods: A convenience sample of adult patients presenting to the one of three hospitals affiliated with the University of Alberta with symptoms of acute AFF were enrolled, within a fee-for-service billing environment. Following informed consent, a trained researcher administered a survey to each patient, recorded administrative details (e.g., triage, times, laboratory tests) from the ED information system, a chart review on treatments was conducted and patients were contacted for follow-up at 7 days via telephone. Descriptive (median and interquartile range {IQR} and proportions) and simple (t-tests, chi-square) statistics are presented for continuous and dichotomous outcomes, respectively. Results: Overall, 217 patients were enrolled; the median age was 64 (IQR: 55, 73) and 132 (61%) were male. Overall, 42 (19.4%) patients arrived by ambulance; 8 (4%) spontaneously converted or were diagnosed with another arrhythmia between arrival and obtaining an ECG. A prior history of AFF was common 152 (71%), as were the following cardiovascular and other risk factors: 176 (81.1%) consumed alcohol, 104 (48%) were current or former smokers, 86 (39.6%) had hypertension, 22 (10%) had CAD, and 10 (5%) had COPD. These patients most commonly reported palpitations 183 (84%) as their dominant symptom. Anti-platelets and anticoagulants were common prior to the ED 145 (67%), and 36 (17%) of patients were discharged from the ED without one of these medications. Overall, 80 (37%) patients had chronic AFF or an unknown timeline; no efforts were made to restore NSR in these patients. A dominant pattern for electrical cardioversion was observed; of 129 cases where cardioversion was attempted, 84 (65%) had electrical first and 45 (35%) had chemical first cardioversion attempts. Overall, 22 (49%) of 45 patients receiving chemical first were successfully converted to NSR. Patients with AFF history who were cardioverted were less likely hospitalized than those not-cardioverted (3% vs. 16%, p=0.006); 21 (10%) were admitted to hospital. Conclusion: In this center, patients with AFF often present to the ED with high acuity, with severe symptoms and receive aggressive care. The use of anticoagulants suggests an appreciation of thrombo-embolic risks, both in the community and ED settings. Like many EDs, this center appears to have a signature for AFF management, related to evidence gaps, physician preferences, and perhaps funding models.