title: The AFFORD clinical decision aid to identify emergency department patients with atrial fibrillation at low risk for 30-day adverse events.
abstract: There is wide variation in the management of patients with atrial fibrillation (AF) in the emergency department (ED). We aimed to derive and internally validate the first prospective, ED-based clinical decision aid to identify patients with AF at low risk for 30-day adverse events. We performed a prospective cohort study at a university-affiliated tertiary-care ED. Patients were enrolled from June 9, 2010, to February 28, 2013, and followed for 30 days. We enrolled a convenience sample of patients in ED presenting with symptomatic AF. Candidate predictors were based on ED data available in the first 2 hours. The decision aid was derived using model approximation (preconditioning) followed by strong bootstrap internal validation. We used an ordinal outcome hierarchy defined as the incidence of the most severe adverse event within 30 days of the ED evaluation. Of 497 patients enrolled, stroke and AF-related death occurred in 13 (3%) and 4 (<1%) patients, respectively. The decision aid included the following: age, triage vitals (systolic blood pressure, temperature, respiratory rate, oxygen saturation, supplemental oxygen requirement), medical history (heart failure, home sotalol use, previous percutaneous coronary intervention, electrical cardioversion, cardiac ablation, frequency of AF symptoms), and ED data (2 hours heart rate, chest radiograph results, hemoglobin, creatinine, and brain natriuretic peptide). The decision aid's c-statistic in predicting any 30-day adverse event was 0.7 (95% confidence interval 0.65, 0.76). In conclusion, in patients with AF in the ED, Atrial Fibrillation and Flutter Outcome Risk Determination provides the first evidence-based decision aid for identifying patients who are at low risk for 30-day adverse events and candidates for safe discharge.
authors: Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee. Electronic address: tyler.barrett@vanderbilt.edu.
authors: Tyler W
authors: TW
authors: Barrett
authors: Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
authors: Alan B
authors: AB
authors: Storrow
authors: Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee.
authors: Cathy A
authors: CA
authors: Jenkins
authors: Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
authors: Robert L
authors: RL
authors: Abraham
authors: Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee.
authors: Dandan
authors: D
authors: Liu
authors: Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
authors: Karen F
authors: KF
authors: Miller
authors: Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
authors: Kelly M
authors: KM
authors: Moser
authors: Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
authors: Stephan
authors: S
authors: Russ
authors: Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Division of Clinical Pharmacology, Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee.
authors: Dan M
authors: DM
authors: Roden
authors: Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee.
authors: Frank E
authors: FE
authors: Harrell
authors: Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Division of Clinical Pharmacology, Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee.
authors: Dawood
authors: D
authors: Darbar
mesh_terms: D000368:Aged; D000465:Algorithms; D001281:Atrial Fibrillation / Q000150:complications* / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D003661:Decision Support Techniques; D004636:Emergency Service, Hospital; D005260:Female; D005500:Follow-Up Studies; D006785:Hospitals, University; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D015203:Reproducibility of Results; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000175:diagnosis* / Q000209:etiology* / Q000401:mortality / Q000628:therapy; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States
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