Variation in management of recent-onset atrial fibrillation and flutter among academic hospital emergency departments.
OBJECTIVE
Although recent-onset atrial fibrillation and flutter are common arrhythmias managed in the emergency department (ED), there is insufficient evidence to help physicians choose between 2 competing treatment strategies, rate control and rhythm control. We seek to evaluate variation in ED management practices for recent-onset atrial fibrillation and flutter patients at multiple Canadian sites and to determine whether hospital site was an independent predictor of attempted cardioversion.


METHODS
We conducted a cross-sectional survey by health records review on an observational cohort of all eligible adult recent-onset atrial fibrillation and flutter cases, with onset of symptoms less than 48 hours, treated at 8 academic hospital EDs during a 12-month period, and evaluated the variation in practice among sites for important management strategies.


RESULTS
Among the 1,068 study patients, 88.3% had atrial fibrillation and 11.7% had atrial flutter. The proportion of cases managed with rhythm control was 59.4% (interhospital range 42% to 85%) and, among these, electrocardioversion was attempted first for 44.2% (range 7% to 69%). There was variation in most management strategies, including use of rate control drugs 54.9% (range 37% to 65%), choice of procainamide as rhythm control drug 62.1% (range 15% to 89%), referral to cardiology in the ED 30.7% (range 16% to 64%), use of heparin 13.7% (range 1% to 29%), and outpatient cardiology referral 43.0% (range 30% to 65%). Adverse events were relatively uncommon and transient for patients undergoing attempts at pharmacologic (13.0%) or electrocardioversion (12.1%). Overall, 83.3% of patients were discharged home from the ED (range 73% to 90%). After controlling for 12 covariates, multivariate logistic regression found that factors independently associated with attempted cardioversion were age (odds ratio [OR] 0.97; 95% confidence interval [CI] 0.95 to 0.98), history of electrocardioversion (OR 2.73; 95% CI 1.56 to 4.80), associated heart failure (OR 0.29; 95% CI 0.09 to 0.95), and hospital site (ORs ranged from 0.38 to 3.05).


CONCLUSIONS
We demonstrated a high degree of variation in management approaches for recent-onset atrial fibrillation and flutter patients treated in academic hospital EDs. Individual hospital site, age, previous cardioversion, and associated heart failure were independent predictors for the use of rhythm control.
Stiell
Ian G
IG
Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada. istiell@ohri.ca
Clement
Catherine M
CM
Brison
Robert J
RJ
Rowe
Brian H
BH
Borgundvaag
Bjug
B
Langhan
Trevor
T
Lang
Eddy
E
Magee
Kirk
K
Stenstrom
Rob
R
Perry
Jeffrey J
JJ
Birnie
David
D
Wells
George A
GA
D000046:Academic Medical Centers / Q000706:statistics & numerical data; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000889:Anti-Arrhythmia Agents / Q000009:adverse effects / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000188:drug therapy / Q000628:therapy*; D001282:Atrial Flutter / Q000188:drug therapy / Q000628:therapy*; D002170:Canada; D016001:Confidence Intervals; D003430:Cross-Sectional Studies; D004554:Electric Countershock / Q000009:adverse effects / Q000706:statistics & numerical data; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D005343:Fibrinolytic Agents / Q000009:adverse effects / Q000627:therapeutic use; D006493:Heparin / Q000009:adverse effects / Q000627:therapeutic use; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011342:Procainamide / Q000009:adverse effects / Q000627:therapeutic use; D055815:Young Adult
D000889:Anti-Arrhythmia Agents; D005343:Fibrinolytic Agents; D006493:Heparin; D011342:Procainamide