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Andrade JG, Macle L. Atrial Fibrillation in the Emergency Department: More Than "Meet 'Em, Treat 'Em, and Street 'Em". Can J Cardiol 2024; 40:1563-1565. [PMID: 38346668 DOI: 10.1016/j.cjca.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 02/01/2024] [Accepted: 02/05/2024] [Indexed: 05/13/2024] Open
Affiliation(s)
- Jason G Andrade
- Vancouver General Hospital, Vancouver, British Columbia, Canada; Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Quebec, Canada.
| | - Laurent Macle
- Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Quebec, Canada
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2
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Stiell IG, Taljaard M, Beanlands R, Johnson C, Golian M, Green M, Kwok E, Brown E, Nemnom MJ, Eagles D. RAFF-5 Study to Improve the Quality and Safety of Care for Patients Seen in the Emergency Department With Acute Atrial Fibrillation and Flutter. Can J Cardiol 2024; 40:1554-1562. [PMID: 38331027 DOI: 10.1016/j.cjca.2024.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND We sought to improve the immediate and subsequent care of emergency department (ED) patients with acute atrial fibrillation (AF) and flutter (AFL) by implementing the principles of the Canadian Association of Emergency Physicians AF/AFL Best Practices Checklist. METHODS This cohort study included 3 periods: before (7 months), intervention introduction (1 month), and after (7 months), and was conducted at a major academic centre. We included patients who presented with an episode of acute AF or AFL and used multiple strategies to support ED adoption of the Canadian Association of Emergency Physicians checklist. We developed new cardiology rapid-access follow-up processes. The main outcomes were unsafe and suboptimal treatments in the ED. RESULTS We included 1108 patient visits, with 559 in the before and 549 in the after period. In a comparison of the periods, there was an increase in use of chemical cardioversion (20.6% vs 25.0%; absolute difference [AD], 4.4%) and in electrical cardioversion (39.2% vs 51.2%; AD, 12.0%). More patients were discharged with sinus rhythm restored (66.9% vs 75.0%; AD, 8.1%). The proportion seen in a follow-up cardiology clinic increased from 24.2% to 39.9% (AD, 15.7%) and the mean time until seen decreased substantially (103.3 vs 49.0 days; AD, -54.3 days). There were very few unsafe cases (0.4% vs 0.7%) and, although there was an increase in suboptimal care (19.5% vs 23.1%), overall patient outcomes were excellent. CONCLUSIONS We successfully improved the care for ED patients with acute AF/AFL and achieved more frequent and more rapid cardiology follow-up. Although cases of unsafe management were uncommon and patient outcomes were excellent, there are opportunities for physicians to improve their care of acute AF/AFL patients. CLINICALTRIALS GOV IDENTIFIER NCT05468281.
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Affiliation(s)
- Ian G Stiell
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
| | - Monica Taljaard
- Ottawa Hospital Research Institute, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Rob Beanlands
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Christopher Johnson
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Mehrdad Golian
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Martin Green
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Edmund Kwok
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Erica Brown
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Debra Eagles
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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Moser N, Omar MA, Koshman SL, Lin M, Youngson E, Kent W, Harten C. Direct oral anticoagulants for atrial fibrillation in early postoperative valve repair or bioprosthetic replacement. J Thorac Cardiovasc Surg 2024; 168:523-532.e3. [PMID: 37061910 DOI: 10.1016/j.jtcvs.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/30/2023] [Accepted: 03/07/2023] [Indexed: 04/17/2023]
Abstract
OBJECTIVE Despite increased use of direct oral anticoagulants (DOACs), limited evidence guides their use in the early postoperative period after bioprosthetic valve implantation in patients with atrial fibrillation. Our objective was to describe the efficacy and safety of DOACs and warfarin in the first 3 months after surgical bioprosthetic valve replacement or repair in patients with atrial fibrillation. METHODS This was a retrospective, registry-informed cohort study of surgical patients who underwent bioprosthetic valve replacement or repair, had concomitant atrial fibrillation and received oral anticoagulation at discharge. The primary efficacy outcome was a composite of death, ischemic stroke, transient ischemic attack, and systemic embolism; the primary safety outcome was a composite of major bleeding. Key secondary outcomes were comparative analyses of primary outcomes, temporal anticoagulation prescribing patterns, and 30-day readmission rates. RESULTS A total of 1743 patients were included. Of the 570 patients in the DOAC group, 17 (2%) met the composite efficacy outcome and 55 (10%) met the composite safety outcome. Of the 1173 patients receiving warfarin, 41 (3%) and 114 (10%) met the composite efficacy and safety outcomes, respectively. Comparative secondary analysis was not statistically significant for either the efficacy (adjusted odds ratio, 0.85; 95% confidence interval, 0.46-1.55, P = .59) or safety (adjusted odds ratio, 0.94; 95% confidence interval, 0.66-1.34, P = .76) outcomes. The 30-day readmission rates were similar between both groups. CONCLUSIONS Our results suggest DOACs may be safe and effective alternatives to warfarin in the early postoperative period after valve repair or surgical bioprosthetic replacement. Confirmation awaits adequately powered prospective studies.
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Affiliation(s)
- Nils Moser
- Pharmacy Services, Alberta Health Services, Edmonton, Alberta, Canada.
| | - Mohamed A Omar
- Pharmacy Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - Sheri L Koshman
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Mu Lin
- Data and Research Services, Alberta SPOR Support Unit and Provincial Research Data Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - Erik Youngson
- Data and Research Services, Alberta SPOR Support Unit and Provincial Research Data Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - William Kent
- Section of Cardiac Surgery, Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | - Cheryl Harten
- Pharmacy Services, Alberta Health Services, Edmonton, Alberta, Canada
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Maille B, Defaye P, Bentounes SA, Herbert J, Clerc JM, Pierre B, Torras O, Deharo JC, Fauchier L. Outcomes Associated With Left Atrial Appendage Occlusion Via Implanted Device in Atrial Fibrillation. Mayo Clin Proc 2024; 99:754-765. [PMID: 38180394 DOI: 10.1016/j.mayocp.2023.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 05/12/2023] [Accepted: 05/30/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVE To compare outcomes after left atrial appendage occlusion (LAAO) via implanted device vs no LAAO in a matched cohort of patients with atrial fibrillation (AF). METHODS This longitudinal retrospective cohort study was based on the national database covering hospital care for the entire French population. Adults (≥18 years of age) who had been hospitalized with AF (January 1, 2015, to January 1, 2020) who underwent LAAO were identified. Propensity score matching was used to control for potential confounders of the treatment-outcome relationship. The primary outcome was a composite of ischemic stroke, major bleeding, or all-cause death during follow-up. RESULTS After propensity score matching, 1216 patients with AF who were treated with LAAO were matched with 1216 controls (patients AF who were not treated with LAAO). Mean follow-up was 14.5 months (median, 13 months; IQR, 7-21 months). Patients with LAAO had a lower risk of the composite outcome (HR, 0.48; 95% CI, 0.42 to 0.55). Total events (309 for LAAO vs 640 for controls) and event rates (23.3% vs 44.0%/year, respectively) were lower for LAAO, driven primarily by a decreased risk of all-cause death (HR, 0.39; 95% CI, 0.33 to 0.46; P<.0001), whereas ischemic stroke risk was higher (HR, 1.75; 95% CI, 1.17 to 2.64). Significant interactions were observed in subgroups with a history of ischemic stroke (P<.001) and of bleeding (P=.002). CONCLUSION Among AF patients at high bleeding risk, our nationwide study highlights a high risk of clinical events during follow-up. LAAO appeared less effective than no LAAO in preventing stroke but more effective in preventing death. Left atrial appendage occlusion is particularly effective in patients with previous ischemic stroke or any episode of bleeding.
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Affiliation(s)
- Baptiste Maille
- Service de Cardiologie, Centre Hospitalier Universitaire La Timone, Assistance Publique - Hôpitaux de Marseille, Aix Marseille University, Marseille, France
| | - Pascal Defaye
- Service de Cardiologie, Centre Hospitalier Universitaire Grenoble Alpes, Unite de Rythmologie, Grenoble, France
| | - Sid Ahmed Bentounes
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau, Faculté de Médecine, Université François Rabelais, Tours, France
| | - Julien Herbert
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau, Faculté de Médecine, Université François Rabelais, Tours, France
| | - Jean Michel Clerc
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau, Faculté de Médecine, Université François Rabelais, Tours, France
| | - Bertrand Pierre
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau, Faculté de Médecine, Université François Rabelais, Tours, France
| | - Olivier Torras
- Service de Cardiologie, Centre Hospitalier Universitaire La Timone, Assistance Publique - Hôpitaux de Marseille, Aix Marseille University, Marseille, France
| | - Jean Claude Deharo
- Service de Cardiologie, Centre Hospitalier Universitaire La Timone, Assistance Publique - Hôpitaux de Marseille, Aix Marseille University, Marseille, France
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau, Faculté de Médecine, Université François Rabelais, Tours, France
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Krahn KM, Koshman SL, Wang T, Chen J, Bungard TJ, Zhou JS, Omar MA, Cowley EC. Anticoagulant Prescribing Patterns in New-Onset Atrial Fibrillation After Cardiac Surgery. Ann Thorac Surg 2024; 117:859-865. [PMID: 38081497 DOI: 10.1016/j.athoracsur.2023.11.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 11/08/2023] [Accepted: 11/20/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery and is associated with an increased risk of thromboembolic stroke. Recommendations regarding the optimal anticoagulant, timing of initiation, and duration of therapy remain uncertain. METHODS Administrative databases were used to include adult patients who presented with POAF after cardiac surgery between January 1, 2015, and December 31, 2020. Key exclusion criteria included preexisting atrial fibrillation, mechanical valve replacement, or anticoagulant prescription fill within 6 months before the index admission. RESULTS A total of 3214 of patients were included, and 878 (27.3%) were prescribed an oral anticoagulant (OAC) on discharge, with 536 (61%) prescribed warfarin and 342 (39%) prescribed a direct OAC. More than half of the patients (56.1%) stopped their OAC by 6 months. There was no difference in stroke or systemic embolism at 30 days, 3 months, or 6 months between those with and without anticoagulation prescribed. However, those on any OAC had higher rates of any bleeding at all time points. CONCLUSIONS A minority of patients who presented with POAF after cardiac surgery were prescribed OAC, with warfarin being the most common agent. OAC initiation was associated with increased bleeding risk, warranting special consideration when assessing a patient's risk of stroke with the increased risk of bleeding, particularly in the postoperative period.
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Affiliation(s)
- Kaitlyn M Krahn
- Department of Pharmacy, Alberta Health Services, Edmonton, Alberta, Canada
| | - Sheri L Koshman
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Ting Wang
- Data and Research Services, Alberta Strategy for Patient Oriented Research Support Unit and Provincial Research Data Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - June Chen
- Department of Pharmacy, Alberta Health Services, Edmonton, Alberta, Canada
| | - Tammy J Bungard
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Jian Song Zhou
- Department of Pharmacy, Alberta Health Services, Edmonton, Alberta, Canada
| | - Mohamed A Omar
- Department of Pharmacy, Alberta Health Services, Edmonton, Alberta, Canada
| | - Emily C Cowley
- Department of Pharmacy, Alberta Health Services, Edmonton, Alberta, Canada.
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Amin K, Bethel G, Jackson LR, Essien UR, Sloan CE. Eliminating Health Disparities in Atrial Fibrillation, Heart Failure, and Dyslipidemia: A Path Toward Achieving Pharmacoequity. Curr Atheroscler Rep 2023; 25:1113-1127. [PMID: 38108997 PMCID: PMC11044811 DOI: 10.1007/s11883-023-01180-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2023] [Indexed: 12/19/2023]
Abstract
PURPOSE OF REVIEW Pharmacoequity refers to the goal of ensuring that all patients have access to high-quality medications, regardless of their race, ethnicity, gender, or other characteristics. The goal of this article is to review current evidence on disparities in access to cardiovascular drug therapies across sociodemographic subgroups, with a focus on heart failure, atrial fibrillation, and dyslipidemia. RECENT FINDINGS Considerable and consistent disparities to life-prolonging heart failure, atrial fibrillation, and dyslipidemia medications exist in clinical trial representation, access to specialist care, prescription of guideline-based therapy, drug affordability, and pharmacy accessibility across racial, ethnic, gender, and other sociodemographic subgroups. Researchers, health systems, and policy makers can take steps to improve pharmacoequity by diversifying clinical trial enrollment, increasing access to inpatient and outpatient cardiology care, nudging clinicians to increase prescription of guideline-directed medical therapy, and pursuing system-level reforms to improve drug access and affordability.
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Affiliation(s)
- Krunal Amin
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Garrett Bethel
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Larry R Jackson
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Utibe R Essien
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, CA, USA
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at the University of California, Los Angeles, CA, USA
- Center for the Study of Healthcare Innovation, Implementation & Policy, Greater Los Angeles VA Healthcare System, Los Angeles, CA, USA
| | - Caroline E Sloan
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA.
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Flippin JA, DeMario BS, Adomshick VJ, Stanley SP, Truong EI, Hendrickson S, Kalina MA, Lasinski AM, Ho VP. Post-Trauma Discharge Instructions: Are We Dropping the Ball? Am Surg 2023; 89:4625-4631. [PMID: 36083613 PMCID: PMC10829078 DOI: 10.1177/00031348221111515] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
INTRODUCTION Complex follow-up plans for polytrauma patients are compiled at the end of hospitalization into discharge instructions. We sought to identify how often patient discharge instructions incorrectly communicated specialist recommendations. We hypothesized that patients with more complex hospitalizations would have more discharge instruction errors (DI-errors). METHODS We reviewed adult trauma inpatients (March 2017-March 2018), excluding those who left against medical advice or were expected to follow up outside our system. Complex hospitalizations were represented using injury severity (ISS), hospital length of stay (LOS), intensive care unit length of stay (iLOS), and number of consultants (NC). We recorded the type of consultant (surgical or nonsurgical), and consultant recommendations for follow-up. DI-errors were defined as either follow-up necessary but omitted or follow-up not necessary yet present on the instructions. Patients with DI-errors were compared to patients without DI-errors. Groups were compared using Wilcoxon rank sum or chi-square (alpha <.05). RESULTS We included 392 patients (median age 45 [IQR 26-58], ISS 14 [10-21], LOS 6 [3-11]). 55 patients (14%) had DI-errors. Factors associated with DI-errors included the total number of consultants and use of nonsurgical consultants. ISS, LOS, iLOS, were not associated with DI-errors. CONCLUSION Common measures of admission complexity were not associated with DI-errors, although the number and type of consultants were associated with DI-errors. Non-surgical specialty consultant recommendations were more likely to be omitted. It is crucial for patients to receive accurate discharge instructions, and systematic processes are needed to improve communication with the patients at discharge.
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Affiliation(s)
| | | | | | | | - Evelyn I. Truong
- Department of Surgery, MetroHealth Medical Center, Cleveland, OH
| | - Sarah Hendrickson
- Community Trauma Institute, MetroHealth Medical Center, Cleveland, OH
| | - Mark A. Kalina
- Community Trauma Institute, MetroHealth Medical Center, Cleveland, OH
| | | | - Vanessa P. Ho
- Department of Surgery, MetroHealth Medical Center, Cleveland, OH
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH
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Carter J, Kirwan C, Niaz S, Baweja S, Al-Haimus F, Hu Y, Ramsden S, Clayton N, de Wit K. Anticoagulation prescription among atrial fibrillation patients managed with and without an anticoagulant initiation pathway: a cohort study. Eur J Emerg Med 2023; 30:365-370. [PMID: 37598348 DOI: 10.1097/mej.0000000000001072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
BACKGROUND AND IMPORTANCE The Canadian Association of Emergency Physicians atrial fibrillation (AF) checklist advises that emergency physicians initiate anticoagulation therapy for patients with AF or flutter who are CHADS65 positive. OBJECTIVES The aim was to compare anticoagulation initiation rates between patients treated with and without an anticoagulation assessment pathway (the SAFE pathway). DESIGN This was a retrospective cohort study. SETTINGS AND PARTICIPANTS All emergency department patients were discharged home with a diagnosis of AF between June 2018 and May 2020 at two Canadian emergency departments. INTERVENTION The SAFE pathway is a hard copy form which allows emergency physicians to document contraindications to anticoagulation, the positive components of the CHADS65 score, and details how to prescribe anticoagulation. OUTCOME MEASURES AND ANALYSIS Trained researchers abstracted data on the use of the SAFE pathway by the presence or absence of the completed, scanned pathway in the electronic medical chart. The exposure of interest was use of this pathway. Patients were followed forward in time for 90 days by electronic medical record review to document stroke, transient ischemic attack, arterial embolism and major bleeding events. All events were independently adjudicated. Adjusted odds ratios were calculated to compare outcomes between those managed with and without the SAFE pathway. RESULTS In total, 766 patients were included, of whom 264 were already taking anticoagulation, 166 were CHADS65 negative and 65 had a contraindication to anticoagulation, leaving 271 patients eligible for anticoagulation prescription. Among the 271 eligible patients, 137/166 managed with the SAFE pathway were initiated on anticoagulation and 24/105 managed without the SAFE pathway started anticoagulation (adjusted odds ratio 25.9; 13.1-51.2). There was no statistically significant difference in the 90-day rate of stroke or bleeding. CONCLUSION Use of the SAFE pathway was associated with a higher rate of anticoagulation prescription.
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Affiliation(s)
- Jaimee Carter
- Department of Family Medicine, Queen's University, Kingston
| | | | - Saghar Niaz
- Department of Medicine, McMaster University, ON
| | - Shriya Baweja
- Department of Anatomy and Cell Biology, McGill University, Montreal, QC
| | - Fayad Al-Haimus
- Division of Emergency Medicine, Department of Medicine, University of Toronto, ON
| | - Yang Hu
- Department of Medicine, McMaster University, ON
| | - Sophie Ramsden
- Division of Emergency Medicine, Department of Medicine, McMaster University
| | - Natasha Clayton
- Department of Medicine, McMaster University
- Emergency Department, Hamilton Health Sciences, Hamilton
| | - Kerstin de Wit
- Division of Emergency Medicine, Department of Medicine, McMaster University
- Departments of Emergency Medicine and Medicine, Queen's University, Kingston
- Department of HEI McMaster University, Hamilton, ON, Canada
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Manzo-Silberman S, Chouihed T, Fraticelli L, Charpentier S, Claustre C, Bonnefoy-Cudraz E, Elbaz M, Peiretti A, Taboulet P, Waintraub X, Roubille F, El Khoury C. Assessment of atrial fibrillation in European emergency departments: insights from a prospective observational multicenter study. Minerva Cardiol Angiol 2023; 71:444-455. [PMID: 36422468 DOI: 10.23736/s2724-5683.22.06179-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND The diagnosis and management of atrial fibrillation (AF) in emergency departments (EDs) have not been well described in France, with limited EU research. This study aimed to describe the diagnosis, management, and prognosis of AF patients in French EDs. METHODS A prospective, observational 2-month study in adults diagnosed with AF was conducted at 32 French EDs. Data regarding patient characteristics, diagnosis, and treatment at EDs were collected, with 12-month follow-up. RESULTS The study included a total of 1369 patients diagnosed with AF at an ED: 279 patients (20.4%) with idiopathic AF (no identified cause of the AF) and 1090 (79.6%) with secondary AF (with a principal diagnosis identified as the cause of AF). Patients were aged 84 years (median) and 51.3% were female. Significantly more idiopathic AF patients than secondary AF patients underwent CHA<inf>2</inf>DS<inf>2</inf>-VASc assessment (67.8% vs. 52.1%,) or echocardiography (21.2% vs. 8.3%), or received an oral anticoagulant and/or antiarrhythmic (62.0% vs. 12.9%). Idiopathic AF patients also had significantly higher rates of discharge to home (36.4% vs. 20.4%) and 3-month cardiologist follow-up (67.0% vs. 41.1%). At 12 months, 96% of patients with follow-up achieved sinus rhythm. The estimated Kaplan-Meier 12-month mortality rate was significantly lower with idiopathic AF than secondary AF (11.9% vs. 34.5%). CONCLUSIONS Patients diagnosed with idiopathic or secondary AF at the ED presented heterogeneous characteristics and prognoses, with those with secondary AF having worse outcomes. Further studies are warranted to optimize patients' initial evaluation in EDs and provide appropriate follow-up.
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Affiliation(s)
- Stéphane Manzo-Silberman
- Institute of Cardiology, Pitié-Salpêtrière Hospital, AP-HP, Sorbonne University, ACTION Study Group, Paris, France -
| | - Tahar Chouihed
- Emergency Department, University Hospital of Nancy, University of Lorraine, Vandoeuvre-les-Nancy, France
- Cliniques-Inserm 1433 Investigation Center, Inserm UMR_S 1116, F-CRIN INI-CRCT, Vandoeuvre-les-Nancy, France
| | - Laurie Fraticelli
- Auvergne Rhône-Alpes Agency for Health, RESCUe Network, Lyon, France
- EA4129, Systemic Health Pathway Laboratory, Lyon, France
| | | | - Clément Claustre
- Auvergne Rhône-Alpes Agency for Health, RESCUe Network, Lyon, France
| | | | - Meyer Elbaz
- Department of Cardiology, Rangueil University Hospital, Toulouse, France
| | | | - Pierre Taboulet
- Emergency Department, Saint-Louis Hospital, AP-HP, Paris, France
| | - Xavier Waintraub
- Institute of Cardiology, Pitié-Salpêtrière Hospital, AP-HP, Sorbonne University, ACTION Study Group, Paris, France
| | - François Roubille
- Department of Cardiology, Montpellier University Hospital, Montpellier, France
| | - Carlos El Khoury
- Clinical Research Unit, Emergency Department, Médipôle Hôpital Mutualiste, Lyon, France
- HESPER EA7425, University Lyon1, Lyon, France
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Sandhu RK, Seiler A, Johnson CJ, Bunch TJ, Deering TF, Deneke T, Kirchhof P, Natale A, Piccini JP, Russo AM, Hills MT, Varosy PD, Araia A, Smith AM, Freeman J. Heart Rhythm Society Atrial Fibrillation Centers of Excellence Study: A survey analysis of stakeholder practices, needs, and barriers. Heart Rhythm 2022; 19:1039-1048. [PMID: 35428582 DOI: 10.1016/j.hrthm.2022.02.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/31/2022] [Accepted: 02/17/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND An integrated, coordinated, and patient-centered approach to atrial fibrillation (AF) care delivery may improve outcomes and reduce cost. OBJECTIVE The purpose of this study was to gain a better understanding from key stakeholder groups on current practices, needs, and potential barriers to implementing optimal integrated AF care. METHODS A series of comprehensive questionnaires were designed by the Heart Rhythm Society Atrial Fibrillation Centers of Excellence (CoE) Task Force to conduct surveys with physicians, advanced practice professionals, patients, and hospital administrators. Data collected focused on the following areas: access to care, stroke prevention, education, AF quality improvement, and AF CoE needs and barriers. Survey responses were collated and analyzed by the Task Force. RESULTS The surveys identified 5 major unmet needs: (1) Standardized protocols, order sets, or care pathways in the emergency department or inpatient setting were uncommon (36%-42%). (2) All stakeholders agreed stroke prevention was a top priority; however, prior bleeding or risk of bleeding was the most frequent barrier for initiation. (3) Patients indicated that education on modifiable causes, AF-related complications, and lowering stroke risk is most important. (4) Less than half (43%) of the health care systems track patients with AF or treatment status. Patients reported that stroke and heart failure prevention and access to procedures were priority areas for an AF CoE. The most common barriers to implementing AF CoE identified by clinicians were administrative support (69%) and cost (52%); administrators reported physical space (43%). CONCLUSION On the basis of the findings of this study, the Task Force identified high priority areas to develop initiatives to aid the implementation of AF CoE.
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Affiliation(s)
- Roopinder K Sandhu
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
| | | | - Colleen J Johnson
- Southeast Louisiana Veterans Healthcare System, Tulane University, New Orleans, Louisiana
| | - T Jared Bunch
- University of Utah School of Medicine, Salt Lake City, Utah
| | | | | | - Paulus Kirchhof
- University Heart and Vascular Center UKE Hamburg, Hamburg, Germany
| | | | | | - Andrea M Russo
- Cooper Medical School at Rowan University, Camden, New Jersey
| | | | - Paul D Varosy
- VA Eastern Colorado Health Care Systems, Aurora, Colorado; University of Colorado, Aurora, Colorado
| | - Almaz Araia
- Heart Rhythm Society, Washington, District of Columbia
| | | | - James Freeman
- Yale University School of Medicine, New Haven, Connecticut
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11
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Johnson AE, Swabe GM, Addison D, Essien UR, Breathett K, Brewer LC, Mazimba S, Mohammed SF, Magnani JW. Relation of Household Income to Access and Adherence to Combination Sacubitril/Valsartan in Heart Failure: A Retrospective Analysis of Commercially Insured Patients. Circ Cardiovasc Qual Outcomes 2022; 15:e009179. [PMID: 35549378 PMCID: PMC9308667 DOI: 10.1161/circoutcomes.122.009179] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Outcomes in heart failure with reduced ejection fraction (HFrEF), are influenced by access and adherence to guideline-directed medical therapy. Our objective was to study the association between annual household income and: (1) the odds of having a claim for sacubitril/valsartan among insured patients with HFrEF and (2) medication adherence (measured as the proportion of days covered [PDC]). We hypothesized that lower annual household income is associated with decreased odds of having a claim for and adhering to sacubitril/valsartan. Methods: Using the Optum de-identified Clinformatics® Data Mart, patients with HFrEF and ≥6 months of enrollment for follow up (2016-2020) were included. Covariates included age, sex, race, ethnicity, educational attainment, US region, number of prescribed medications, and Elixhauser Comorbidity Index. Prescription for sacubitril/valsartan was defined by the presence of a claim within 6 months of HFrEF diagnosis. Adherence was defined as PDC≥80%. We fit multivariable-adjusted logistic regression models and hierarchical logistic regression accounting for covariates. Results: Among 322,007 individuals with incident HFrEF, 135,282 had complete data for analysis. Of the patients eligible for sacubitril/valsartan, 4.7% (6,372) had a claim within 6 months of HFrEF diagnosis. Following multivariable adjustment, individuals in the lowest annual income category (<$40,000) were significantly less likely (OR=0.83, 95% CI [0.76, 0.90]) to have a sacubitril/valsartan claim within 6 months of HFrEF diagnosis than those in the highest annual income category (≥$100,000). Annual income <$40,000 was associated with lower odds of PDC≥80% compared with income ≥$100,000 (OR=0.70, 95% CI [0.59, 0.83]). Conclusions: Lower household income is associated with decreased likelihood of a sacubitril/valsartan claim and medication adherence within 6 months of HFrEF diagnosis, even after adjusting for sociodemographic and clinical factors. Future analyses are needed to identify additional social factors associated with delays in sacubitril/valsartan initiation and long-term adherence.
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Affiliation(s)
- Amber E Johnson
- Heart and Vascular Institute University of Pittsburgh Medical Center Pittsburgh PA; Division of Cardiology, University of Pittsburgh School of Medicine, PA
| | - Gretchen M Swabe
- Division of Cardiology, University of Pittsburgh School of Medicine, PA
| | - Daniel Addison
- Division of Cardiovascular Medicine and the Davis Heart and Lung Research Institute, The Ohio State University, OH
| | - Utibe R Essien
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, PA; Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh PA
| | | | - LaPrincess C Brewer
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN; Center for Health Equity and Community Engagement Research, Mayo Clinic, Rochester, MN
| | - Sula Mazimba
- Division of Cardiovascular Medicine, Advanced Heart Failure and Transplant Center, University of Virginia, VA
| | | | - Jared W Magnani
- Heart and Vascular Institute University of Pittsburgh Medical Center Pittsburgh PA; Division of Cardiology, University of Pittsburgh School of Medicine, PA
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12
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Abstract
The COVID-19 pandemic has rapidly emerged as one of the biggest public health concerns of the 21st century. Although it was initially reported as a cluster of pneumonia cases, it quickly became apparent that COVID-19 is not merely a respiratory tract infection. Its clinical course is often complicated by cardiovascular manifestations including venous and arterial thrombosis, electrical disturbances, and myocardial damage. In addition, the cardiovascular system is involved not only during infection but also preceding the contraction of the virus; having cardiovascular comorbidities indicates significant vulnerability to the pathogen. As longer-term data continue to accumulate, we now have concerns over its lasting cardiovascular effects after recovery. Moreover, there have been substantial collateral effects on the epidemiology of cardiovascular diseases. Reports of adverse cardiovascular events from vaccination have emerged as new hurdles to our efforts to bring an end to the pandemic. As such, the association between COVID-19 and the cardiovascular system and cardiovascular practice in general is expansive. In this review, we provide an overview of the knowledge and considerations in this field, based on the evidence available at the time of this writing.
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Affiliation(s)
- Daiki Tomidokoro
- Department of Cardiology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yukio Hiroi
- Department of Cardiology, National Center for Global Health and Medicine, Tokyo, Japan.
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13
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Mendoza PA, McIntyre WF, Belley-Côté EP, Wang J, Parkash R, Atzema CL, Benz AP, Oldgren J, Whitlock RP, Healey JS. Oral anticoagulation for patients with atrial fibrillation in the ED: RE-LY AF registry analysis. J Thromb Thrombolysis 2021; 53:74-82. [PMID: 34338944 DOI: 10.1007/s11239-021-02530-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/10/2021] [Indexed: 11/27/2022]
Abstract
Oral anticoagulation (OAC) reduces stroke risk in patients with atrial fibrillation (AF). We sought to determine predictors of OAC initiation in AF patients presenting to the emergency department (ED). Secondary analysis of the RE-LY AF registry which enrolled individuals from 47 countries between 2007 and 2011 who presented to an ED with AF and followed them for 1 year. A total of 4149 patients with AF as their primary diagnosis who were not already taking OAC and had a CHA2DS2-VASc ≥ 1 for men or ≥ 2 for women were included in this analysis. Of these individuals, 26.8% were started on OAC (99.2% vitamin K antagonists) in the ED and 29.8% were using OAC one year later. Factors associated with initiating OAC in the ED included: specialist consultation (relative risk [RR] 1.84, 95%CI 1.44-2.36), rheumatic heart disease (RR 1.60, 95%CI 1.29-1.99), persistence of AF at ED discharge (RR 1.33, 95%CI 1.18-1.50), diabetes mellitus (RR 1.32, 95%CI 1.19-1.47), and hospital admission (RR 1.30, 95%CI 1.14-1.47). Heart failure (RR 0.83, 95%CI 0.74-0.94), antiplatelet agents (RR 0.77, 95%CI 0.69-0.84), and dementia (RR 0.61, 95%CI 0.40-0.94) were inversely associated with OAC initiation. Patients taking OAC when they left the ED were more likely using OAC at 1-year (RR 2.81, 95%CI 2.55-3.09) and had lower rates of death (RR 0.55, 95%CI 0.38-0.79) and stroke (RR 0.59, 95%CI 0.37-0.96). In patients with AF presenting to the ED, prompt initiation of OAC and specialist involvement are associated with a greater use of OAC 1 year later and may result in improved clinical outcomes.
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Affiliation(s)
- Pablo A Mendoza
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - William F McIntyre
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Emilie P Belley-Côté
- Population Health Research Institute, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jia Wang
- Population Health Research Institute, Hamilton, ON, Canada
| | - Ratika Parkash
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | | | | | - Jonas Oldgren
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Richard P Whitlock
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Jeff S Healey
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
- Population Health Research Institute, Hamilton, ON, Canada.
- Department of Medicine, McMaster University, Hamilton, ON, Canada.
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14
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Impact of Atrial Fibrillation Case Volume in the Emergency Department on Early and Late Outcomes of Patients With New Atrial Fibrillation. Ann Emerg Med 2021; 78:242-252. [PMID: 34325859 DOI: 10.1016/j.annemergmed.2021.03.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 01/23/2021] [Accepted: 02/10/2021] [Indexed: 12/20/2022]
Abstract
STUDY OBJECTIVE To define the association between atrial fibrillation case volume in the emergency department and death or all-cause hospitalization at 30 days and 1 year in patients with new atrial fibrillation. Secondary objectives examined repeat ED visits and the management of atrial fibrillation within 90 days. METHODS We identified all adults presenting to an ED in Alberta, Canada, with a new primary diagnosis of atrial fibrillation/flutter between 2009 and 2015 using International Classification of Diseases, 10th Revision code I48. Volume was classified in tertiles weighted by annual ED number of atrial fibrillation cases. The association between volume and outcomes was evaluated using generalized linear mixed models, adjusting for prognostically important covariates as fixed effects and ED as a random effect to account for potential clustering within EDs. RESULTS The tertiles consisted of 4 high, 9 medium, and 68 low atrial fibrillation volume EDs, with 4,217, 4,193, and 4,112 patients, respectively. Volume was not independently associated with the primary outcome or individual components. However, medium- and high-volume EDs had fewer repeat ED visits at 30 days (respective adjusted odds ratio [aOR] 0.75 [95% confidence interval {CI} 0.66 to 0.87] and 0.64 [0.52 to 0.79]) and 1 year (respective aOR 0.77 [95% CI 0.67 to 0.90] and 0.71 [0.56 to 0.90]). Fewer patients were admitted from medium- (37.1%) and high- (32.0%) compared with low-volume (39.5%) EDs. Patients attending medium- and high-volume EDs were more likely to be cardioverted (aOR 3.28 [95% CI 1.94 to 5.53] and 3.81 [1.39 to 10.48] for medium- and high-volume EDs, respectively). CONCLUSION Treatment in higher volume EDs was associated with significantly lower admission rates and repeat ED visits but no difference in survival.
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15
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Crijns HJGM, Prinzen F, Lambiase PD, Sanders P, Brugada J. The year in cardiovascular medicine 2020: arrhythmias. Eur Heart J 2021; 42:499-507. [PMID: 33388752 DOI: 10.1093/eurheartj/ehaa1091] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 12/08/2020] [Accepted: 12/19/2020] [Indexed: 12/12/2022] Open
Abstract
of the progress in arrhythmias in 2020. RACE4 and ALL-IN indicated that integrated nurse-led care improves outcomes in AF patients.3,4 The same was reported for early rhythm control therapy15 and cryoablation as initial AF treatment.25,26 Subcutaneous ICD was non-inferior to classical transvenous ICD therapy in PRAETORIAN.54 One mechanistic study showed that autoantibodies against misexpressed actin, keratin, and connexin-43 proteins create a blood-borne biomarker profile enhancing diagnosis of Brugada syndrome.50 Another mechanistic study indicated that transseptal LV pacing yields similar improvement in contractility as His bundle pacing whilst being more easy to execute.44 In PRE-DETERMINE a simple-to-use ECG risk score improved risk prediction in patients with ischemic heart disease possibly enhancing appropriate ICD therapy in high risk patients.58.
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Affiliation(s)
- Harry J G M Crijns
- Department of Cardiology and Cardiovascular Research Centre Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Frits Prinzen
- Department of Physiology and Cardiovascular Research Centre Maastricht (CARIM), University of Maastricht, Maastricht, The Netherlands
| | | | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Josep Brugada
- Cardiovascular Institute, Hospital Clinic, Pediatric Arrhythmia Unit, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
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16
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Rowe BH, McAlister FA, Graham MM, Holroyd BR, Rosychuk RJ. Despite Having Worse Risk Profiles, Northern Albertans Wait Longer for Specialist Follow-up After Emergency Department Visits for Atrial Fibrillation. CJC Open 2020; 2:610-618. [PMID: 33305221 PMCID: PMC7710999 DOI: 10.1016/j.cjco.2020.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/23/2020] [Indexed: 11/12/2022] Open
Abstract
Background Atrial fibrillation and flutter (AFF) are common arrhythmias diagnosed in the emergency department (ED), and prompt follow-up with specialists may yield better outcomes. This study examines time to first specialist outpatient visit following ED discharge for AFF. Methods Alberta residents aged ≥ 35 years with ED presentations for AFF ending in discharge during 2017-2018 were extracted and linked with hospitalizations and physician claims. A spatial scan and multinomial logistic regression were performed. Regression model predictors included demographics, prior diagnoses, and prior health service use. Results ED presentations for 4387 patients (54% male; mean age 68 years) were analyzed. Two geographic areas were identified as clusters that had longer times than would be expected by chance: a north cluster of northern areas with an estimated median time of 98 days (95% confidence interval [CI] 82,139), and an east cluster of eastern areas with a median of 57 days (95% CI 47, 68). Patients in the north cluster were more likely to be younger (adjusted odds ratio [aOR] = 0.76 per 5 years, 95% CI 0.62, 0.93) and have prior histories of AFF (aOR = 1.45, 95% CI 1.11, 1.90), congestive heart failure (aOR=1.51, 95% CI 1.15, 1.98), chronic obstructive pulmonary disease (aOR = 2.03, 95% CI 1.55, 2.65), and diabetes (aOR = 1.30, 95% CI 1.00, 1.67). They were less likely to have prior general practitioner outpatient visits (aOR = 0.65 per 5 visits, 95% CI 0.53, 0.81) and specialist outpatient visits (aOR = 0.39, 95% CI 0.30, 0.50) than other patients. Conclusions Despite being at higher risk, patients in northern areas took longer to see a specialist after an ED presentation for AFF than those from other regions. Innovative strategies for promoting specialist follow-up should be explored.
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Affiliation(s)
- Brian H Rowe
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada.,School of Public Health, University of Alberta, Edmonton, Alberta, Canada.,Institute of Circulatory and Respiratory Health, Canadian Institutes of Health Research, Ottawa, Ontario, Canada.,Alberta Health Services, Edmonton, Alberta, Canada
| | - Finlay A McAlister
- Alberta Health Services, Edmonton, Alberta, Canada.,Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Michelle M Graham
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Brian R Holroyd
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada.,Alberta Health Services, Edmonton, Alberta, Canada
| | - Rhonda J Rosychuk
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.,Women & Children's Health Research Institute, Edmonton, Alberta, Canada
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17
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Crijns HJGM, Wijtvliet EPJ, Pluymaekers NAHA, Van Gelder IC. Newly discovered atrial fibrillation: who(se) care(s)? Europace 2020; 22:677-678. [PMID: 32282897 PMCID: PMC7203630 DOI: 10.1093/europace/euz359] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Harry J G M Crijns
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - E Petra J Wijtvliet
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Nikki A H A Pluymaekers
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
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18
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Andrade JG, Aguilar M, Atzema C, Bell A, Cairns JA, Cheung CC, Cox JL, Dorian P, Gladstone DJ, Healey JS, Khairy P, Leblanc K, McMurtry MS, Mitchell LB, Nair GM, Nattel S, Parkash R, Pilote L, Sandhu RK, Sarrazin JF, Sharma M, Skanes AC, Talajic M, Tsang TSM, Verma A, Verma S, Whitlock R, Wyse DG, Macle L. The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation. Can J Cardiol 2020; 36:1847-1948. [PMID: 33191198 DOI: 10.1016/j.cjca.2020.09.001] [Citation(s) in RCA: 319] [Impact Index Per Article: 79.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/05/2020] [Accepted: 09/05/2020] [Indexed: 12/20/2022] Open
Abstract
The Canadian Cardiovascular Society (CCS) atrial fibrillation (AF) guidelines program was developed to aid clinicians in the management of these complex patients, as well as to provide direction to policy makers and health care systems regarding related issues. The most recent comprehensive CCS AF guidelines update was published in 2010. Since then, periodic updates were published dealing with rapidly changing areas. However, since 2010 a large number of developments had accumulated in a wide range of areas, motivating the committee to complete a thorough guideline review. The 2020 iteration of the CCS AF guidelines represents a comprehensive renewal that integrates, updates, and replaces the past decade of guidelines, recommendations, and practical tips. It is intended to be used by practicing clinicians across all disciplines who care for patients with AF. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to evaluate recommendation strength and the quality of evidence. Areas of focus include: AF classification and definitions, epidemiology, pathophysiology, clinical evaluation, screening and opportunistic AF detection, detection and management of modifiable risk factors, integrated approach to AF management, stroke prevention, arrhythmia management, sex differences, and AF in special populations. Extensive use is made of tables and figures to synthesize important material and present key concepts. This document should be an important aid for knowledge translation and a tool to help improve clinical management of this important and challenging arrhythmia.
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Affiliation(s)
- Jason G Andrade
- University of British Columbia, Vancouver, British Columbia, Canada; Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada.
| | - Martin Aguilar
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Alan Bell
- University of Toronto, Toronto, Ontario, Canada
| | - John A Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Jafna L Cox
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - Paul Dorian
- University of Toronto, Toronto, Ontario, Canada
| | | | | | - Paul Khairy
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | | | - Girish M Nair
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Stanley Nattel
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | | | - Jean-François Sarrazin
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | - Mukul Sharma
- McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada
| | | | - Mario Talajic
- Montreal Heart Institute, University of Montreal, Montréal, Quebec, Canada
| | - Teresa S M Tsang
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Laurent Macle
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
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19
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Allahwala UK, Denniss AR, Zaman S, Bhindi R. Cardiovascular Disease in the Post-COVID-19 Era - the Impending Tsunami? Heart Lung Circ 2020; 29:809-811. [PMID: 32371032 PMCID: PMC7161486 DOI: 10.1016/j.hlc.2020.04.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Usaid K Allahwala
- Department of Cardiology, Royal North Shore Hospital, Sydney, NSW, Australia; The University of Sydney, Sydney, NSW, Australia
| | - A Robert Denniss
- The University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia; Editor-in-Chief, Heart, Lung and Circulation, Sydney, NSW, Australia
| | - Sarah Zaman
- Monash Cardiovascular Research Centre, Monash University, Melbourne, Vic, Australia; Monash Heart, Monash Medical Centre, Melbourne, Vic, Australia
| | - Ravinay Bhindi
- Department of Cardiology, Royal North Shore Hospital, Sydney, NSW, Australia; The University of Sydney, Sydney, NSW, Australia.
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