Atrial fibrillation: prevalence and management in an acute general medical unit

Handheld ECG Tracking of in-hOspital Atrial Fibrillation The HECTO-AF trial Clinical Study Protocol

Background/rationale

Atrial fibrillation (AF) is frequent and causes great morbidity in the aging population. While initial events may be symptomatic, many patients have silent AF and are at risk of ischemic embolic complications. Timely detection of asymptomatic patients is paramount. The HECTO-AF trial aims to investigate the efficacy of an electrocardiogram (ECG) handheld device for the detection of AF in patients in hospital without a prior diagnosis of AF.

Methods/design

The “Handheld ECG tracking of in-hospital atrial fibrillation” (HECTO-AF) study is a single-center, open-label, randomized controlled trial. The study population consists of all adult patients admitted to a general medicine ward of the University and Hospital of Fribourg throughout the study period. The study will enroll 1600 patients with 1:1 ratio allocation to either the detection group with one-lead handheld ECG recordings twice daily and extra recordings in the case of palpitations, versus a control group undergoing detection of AF as per routine clinical practice. Recordings will be self-performed after dedicated training, and will be independently adjudicated through a specific web-based interface. All enrolled patients will be followed clinically at 1, 2 and 5 years to assess the occurrence of AF, death, non-fatal stroke, systemic embolism, myocardial infarction and bleeding. The primary outcome is incidence of newly detected AF during the hospital stay. Secondary outcomes are incidence of AF, cardiovascular death, stroke, myocardial infarction and bleeding complications at 1, 2 and 5 years.

Discussion

HECTO-AF is an independent randomized study aiming to detect the incidence of silent AF in all-comers hospitalized in general medicine wards.

Trial registration

ClinicalTrials.gov, NCT03197090. Registered on 23 June 2017. Local ethical Committee (CER-VD) registration number: 2017–01594. There are no conflicts of interest to declare.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3189-7) contains supplementary material, which is available to authorized users.

Prevalence and antithrombotic management of atrial fibrillation in hospitalised patients

OBJECTIVES

The objective of this study was to determine the prevalence of atrial fibrillation (AF) in a tertiary care centre, to describe the comorbidity profile of hospitalised patients with AF, and to evaluate the appropriateness of their maintenance antithrombotic management.

METHODS

In a cross-sectional, descriptive study, all consenting hospitalised patients from 36 wards in a University hospital (excluding critical care units, psychiatric, maternity and paediatric wards) received an ECG on a single day. Also their charts were reviewed for key demographic and clinical data. For patients with AF, all factors and comorbidities comprising thromboembolic (CHA₂DS₂-VASc) and bleeding risk (HAS-BLED) were listed. The appropriateness of long-term anticoagulant therapy was assessed according to the 2010 international guidelines (CHA₂DS₂-VASc score 0=aspirin or no antithrombotic treatment; 1=aspirin or oral anticoagulant treatment (OAC); ≥2=OAC). The response rate was 79.7%, that is, an ECG was performed in 636 of 812 eligible hospitalised patients.

RESULTS

AF was present on ECG in 58 patients reflecting a 9.1% hospital point prevalence (95% CI 6.9% to 11.3%). Of the remaining 587 participants, 49 had a history of AF. Hence, 107 AF cases were identified, yielding a total prevalence of 16.8% (95% CI 13.9% to 19.7%). Patients with AF were detected in every hospital zone, with highest prevalence rates in zone 'thorax' (29.3% (95% CI 22.2% to 36.4%)) and 'internal medicine' (21.7% (95%CI 14.8% to 28.6%)). Patients with AF were older than patients without AF (78.7±10.3 years versus 62.7±15.9 years; p<0.001). The most common associated comorbidities were hypertension (63.6%) and valvular heart disease (58.9%). Most patients with AF were at high risk for stroke (CHA₂DS₂-VASc-score ≥2 in 92.5%). Overall, only 51.3% of all patients did receive appropriate anticoagulant long-term management, while 31% were undertreated and 17.7% were possibly overtreated.

CONCLUSIONS

This hospital-based study revealed high AF prevalence rates (16.8%). Patients with AF were present in all hospital zones and almost all patients were at high risk for stroke. Anticoagulation management was likely inappropriate in 48.7%, indicating the need for better guideline implementation initiatives to guarantee hospital-wide optimised care for patients with AF.

The global burden of atrial fibrillation and stroke: a systematic review of the epidemiology of atrial fibrillation in regions outside North America and Europe

BACKGROUND

Although atrial fibrillation (AF) is accepted as the most common sustained cardiac arrhythmia, most published epidemiologic studies focus on predominantly white populations in North America or Europe, and information on AF in nonwhite populations is scarce. The objective of this study was to undertake a systematic review of the published literature on the epidemiology of AF in other regions.

METHODS

Systematic literature searches (MEDLINE; 1990-2010) identified epidemiologic studies reporting on the prevalence or incidence of AF, stroke in AF, risk factors for AF, or the use of antithrombotic therapy in countries outside North America and Europe. This report presents a descriptive analysis of the data; no meta-analysis was planned.

RESULTS

Many of the 38 articles identified were from the Far East, although Australia, New Zealand, the Middle East, and South America were also represented. The reported prevalence of AF varied among countries, with different ranges in community- and hospital-based studies (0.1%-4% and 2.8%-14%, respectively). The use of anticoagulant therapy varied widely among countries and studies, as did the reported prevalence of stroke in patients with AF (2.8%-24.2%).

CONCLUSIONS

High-quality epidemiologic studies are clearly required to improve understanding of the worldwide burden of AF and stroke in AF. Major improvements in the provision of thromboprophylaxis are also needed in many countries, given the high proportion of untreated patients who are, hence, at risk of stroke.

Cardiovascular and non-cardiovascular hospital admissions associated with atrial fibrillation: a Danish nationwide, retrospective cohort study

OBJECTIVE

To examine the excess risk of hospitalisation in patients with incident atrial fibrillation (AF).

DESIGN

A nationwide, retrospective cohort study.

SETTING

Denmark.

PARTICIPANTS

Data on all admissions in Denmark from 1997 to 2009 were collected from nationwide registries. After exclusion of subjects previously admitted for AF, data on 4 602 264 subjects and 10 779 945 hospital admissions contributed to the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Age-stratified and sex-stratified admission rates were calculated for cardiovascular and non-cardiovascular admissions. Temporal patterns of readmission, relative risk and duration of frequent types of admission were calculated.

RESULTS

Of 10 779 945 hospital admissions, 729 088(6.8%) were associated with AF. Admissions for cardiovascular reasons after 1, 3 and 6 months occurred for 6.0, 14.3 and 28.4% of AF patients versus 0.2, 0.6 and 1.8 of non-AF patients. Admissions for non-cardiovascular reasons after 1, 3 and 6 months comprised 6.8, 16.1 and 33.3% of AF patients and 1.2, 3.2 and 9.7% of non-AF patients. When stratified for age, AF was associated with similar cardiovascular admission rates across all age groups, while non-cardiovascular admission rates were higher in older patients. Within each age group and for both cardiovascular and non-cardiovascular admissions, AF was associated with higher rates of admission. When adjusted for age, sex and time period, patients with AF had a relative risk of 8.6 (95% CI 8.5 to 8.6) for admissions for cardiovascular reasons and 4.0 (95% CI 4.0 to 4.0) for admission for non-cardiovascular reasons.

CONCLUSIONS

This study confirms that the burden of AF is considerable and driven by both cardiovascular and non-cardiovascular admissions. These findings underscore the importance of using clinical and pharmacological means to reduce the hospital burden of AF in Western healthcare systems.

The health care setting rather than medical speciality impacts on physicians adherence to guideline-conform anticoagulation in outpatients with non-valvular atrial fibrillation: a cross sectional survey

Background

In patients with non-valvular atrial fibrillation (NVAF) at high risk for stroke guidelines consistently recommend long-term oral anticoagulation (OAC) with a vitamin K antagonist. However recommendations remain ambiguous in respect to the precise OAC initiation regimens. Based on the clinical observation, that the initiation of OAC for NVAF varies considerably in daily practice, we aimed to assess the current practice in Switzerland.

Methods

Cross-sectional survey of randomly selected general practitioners, internists and cardiologists from different health care settings in an urban Swiss region that covers 1.4 million inhabitants. The main outcome measures were the preferred antithrombotic initiation regimen and long-term treatment in patients with newly diagnosed NVAF at high risk for stroke.

Results

We received 226 out of 388 (58.2%) surveys. Compared to physicians working in a hospital setting (33.6% of respondents) physicians in ambulatory care reported more years of experience and claimed lower-use (never or seldom) of guidelines in general (47.6 vs. 12.2%). Regarding long-term thromboembolic prophylaxis 93.7% of all responders followed current recommendation by choosing an OAC. When focussing on guideline-consistent correct OAC initiation (either low-dose initial OAC or a combination of LMWH and OAC) adherence dropped to 60.6% with hospital physicians demonstrating a significantly higher use of guideline-conform OAC regimens (79.7 vs. 51.0%). Medical speciality in non-hospital physicians was not related to correct guideline-use. Hospital setting remained independently associated with a guideline-conform OAC initiation regimen (OR 2.8, p = 0.023) when controlled for medical speciality, physicians' characteristics and clinical experience. Problems when starting an anticoagulation treatment were seldom reported (never or seldom accounting for 94.1% of all responses).

Conclusions

The guideline adherence with respect to OAC initiation regimens in NVAF was significantly lower when compared to long-term treatment and health care setting rather than medical speciality explained guideline-conform OAC initiation. The majority of the physicians did not consider the initiation of anticoagulation to be a major obstacle in outpatient care.

Quality of emergency room care for atrial fibrillation

OBJECTIVES

Atrial fibrillation (AF) is the most common arrhythmia in emergency rooms (ER). We surveyed the clinical characteristics and quality of care of AF patients in three emergency rooms in Helsinki, Finland.

DESIGN

Observational data of the treatment of 179 consecutive symptomatic AF patients were prospectively collected. The quality of care was analysed according to a predestined set of criteria.

RESULTS

Mean age of the patients was 63 years and 61% were men. The leading symptom was palpitation (86%). Sinus rhythm was achieved in 70%. New anticoagulation was initiated in 20% and cardiovascular medication modified in 42% of patients. Considering the overall quality of care, including documentation in the patient chart, it was classified as good in 53% of all patients, whereas the quality of therapeutic decisions and planning for follow-up was good in 77%.

CONCLUSIONS

The ER visit results in extensive treatment modifications in two of three patients. Although inadequate care is rare, maintaining good quality requires adherence to clinical guidelines, careful documentation and plans for follow-up.

Acute management of atrial fibrillation

Acute atrial fibrillation (AF) is the most common cardiac rhythm encountered in clinical practice and is commonly seen in acutely ill patients in critical care. In the latter setting, AF may have two main clinical sequelae: (1) haemodynamic instability and (2) thromboembolism. The approach to the management of AF can broadly be divided into a rate control strategy or a rhythm control strategy, and is largely driven by symptom assessment and functional status. A crucial part of AF management requires the appropriate use of thromboprophylaxis. In patients who are haemodynamically unstable with AF, urgent direct current cardioversion should be considered. Apart from electrical cardioversion, drugs are commonly used, and Class I (flecainide, propafenone) and Class III (amiodarone) antiarrhythmic drugs are more likely to revert AF to sinus rhythm. Beta blockers and rate limiting calcium blockers, as well as digoxin, are often used in controlling heart rate in patients with acute onset AF. The aim of this review article is to provide an overview of the management of AF in the critical care setting.

Balancing risk versus benefit: the elderly patient's perspective on warfarin therapy

Warfarin therapy is underused in the target at-risk elderly population. Clinicians perceive that older patients are reluctant to use this therapy, however the perspective of patients or their carers has yet to be explored.

Objective:

To explore in-depth the perspectives of elderly patients and/or their carers regarding the use of warfarin therapy.

Method:

A qualitative study, using semi-structured group interviews was undertaken. The audio-taped discussions were transcribed verbatim, then thematically analysed to identify emergent themes. Group discussions were conducted at a major Sydney teaching hospital, over a 2-month period. Individuals aged 65 years or older (and/or their carers) who were using long-term (6 months) warfarin therapy were recruited by voluntary response to study flyers.

Results:

17 patients and carers (mean age 77.2 SD=7.5 years) participated in one of two focus groups. Five core themes emerged regarding warfarin therapy: inadequate knowledge and understanding about it, patients/carers variable experience of information provision, cycle of reactions to being on it, issues in its practical management, and the spectrum of experiences with it. Overall, participants were very accepting of the therapy, describing a high level of compliance, despite initial fears and anxieties, and a relative lack of knowledge. Patients felt somewhat abandoned in their management of warfarin due to the lack of ongoing support services in the community, and inadequate information provision.

Conclusions:

Elderly patients and their carers appear to be quite accepting of warfarin therapy, in contrast to the perceptions of health care professionals. More effort is needed, however, in terms of information provision, particularly in the form of community-based services, to assist patients in the long-term management of warfarin.

Paroxysmal atrial fibrillation in critically ill patients with sepsis

The objective of this retrospective cohort study was to describe the incidence of paroxysmal atrial fibrillation and to determine its risk factors and effect on outcome in critically ill patients with sepsis. The study included 81 patients with sepsis admitted to an intensive care unit. In all, 25 patients (31%) developed paroxysmal atrial fibrillation. Advanced age, history of paroxysmal atrial fibrillation, higher severity of illness at intensive care unit admission, and lower left ventricular ejection fraction were risk factors for paroxysmal atrial fibrillation. Multiple logistic regression analysis showed that paroxysmal atrial fibrillation was independently associated with 28-day mortality (odds ratio = 3.284; 95% confidence interval, 1.126-9.574). The incidence of paroxysmal atrial fibrillation is high in critically ill patients with sepsis. It occurs more frequently in patients with advanced age, history of paroxysmal atrial fibrillation, high severity of illness, and lower left ventricular ejection fraction and is associated with increased mortality.

Comment on the article by Vázquez and Márquez-Garcia. High-risk vs. low-risk for thrombo-embolic events: Who are in the intermediate-risk group? What should be done then?

Although high risk and low risk profile for thrombo-embolic events have been extensively and intensively investigated in multi-centre trials and described in detail in atrial fibrillation guidelines, the management of those at otherwise intermediate risk is still a 'no-one's zone'. Individual risk profile is mandatory to identify those who will benefit of anti-coagulation therapy and large-scale clinical trials are still awaited to define efficacy and efficiency profile in intermediate-risk group.

Implementation of a Norepinephrine-based Protocol for Management of Septic Shock: A Pilot Feasibility Study

BACKGROUND

The subject of the best vasopressor for hemodynamic management of septic shock (SS) is controversial. One of the difficulties in planning such studies is that physicians are reluctant to use one vasopressor exclusively, and there is considerable variation in practice. The aim of this study was to test the feasibility of implementing a single pressor-based algorithm (in this case, norepinephrine [NE]).

METHODS

A NE-based algorithm was applied prospectively to 100 consecutive SS patients. A formal training program was implemented before starting the protocol and applied to 72 physicians and nurses involved in intensive care unit (ICU) patient care. Compliance, protocol violations, probable adverse effects, and outcome were evaluated on a daily basis by an independent group of fellows and a research nurse.

RESULTS

In 100 patients, there were 7,139 hours of algorithm use. Only 13 protocol violations were observed, mostly in the timing of inotropic drugs. Senior staff physicians or busy night shifts accounted for most of these violations. ICU mortality was 33%, which is comparable to that predicted by Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores. Adverse events probably related to NE were not observed.

CONCLUSIONS

The present algorithm, applied after a strict training program, obtained an overall good acceptance and compliance with very few protocol violations in more than 7,000 hours of use. Safety was demonstrated by a global mortality comparable to that predicted by severity scores and absence of specific drug-related morbidity. The implementation of a single pressor-based algorithm for SS is feasible and safe.

The morbidity related to atrial fibrillation at a tertiary centre in one year: 9.0% of all strokes are potentially preventable

Atrial fibrillation is a major risk factor for stroke. Anticoagulant therapy reduces this risk but increases the risk of haemorrhage. We aimed to compare the morbidity related to the treatment of atrial fibrillation with warfarin seen in one year at our hospital, with the morbidity in those patients in whom embolism was potentially preventable. There were 111 patients admitted to our hospital in a 12 month period with nonvalvular atrial fibrillation (NVAF) who had stroke, TIA or peripheral embolism. Atrial fibrillation was identified prior to admission in 87 of these 111 (78%) patients with thromboembolism, yet only 14 of these (16%) were receiving warfarin for stroke prophylaxis. Through chart review, a further 56 (64%) patients with embolism could have been receiving anticoagulant therapy if published clinical guidelines(1) were applied. Therefore, 40 episodes of thromboembolism were potentially preventable. Over the same period, there were 18 patients admitted with haemorrhage related to warfarin therapy for stroke prophylaxis in NVAF, including 10 gastrointestinal, five intracerebral, and three peripheral haemorrhages. Most haemorrhages were associated with a high International Normalized Ratio (INR) and the patients were left less disabled than those with embolism. Only one patient with haemorrhage had an absolute contraindication to warfarin therapy (6%). We conclude that the number of preventable strokes far outweighed the morbidity due to warfarin use in the management of NVAF.

Implementation of antithrombotic management in atrial fibrillation

The aim of the study was to assess the extent to which published recommendations on the antithrombotic management of atrial fibrillation had been adopted into clinical practice in a busy district general hospital, and the impact of clinical audit on subsequent management. In the initial audit, 185 consecutive patients with atrial fibrillation were studied using their case notes to identify any further clinical risk factors for stroke. A management algorithm stratified patients with atrial fibrillation into high, moderate, or low risk of stroke according to the individual stroke risk factors. For patients at high risk, the correct treatment is warfarin unless there are specific contraindications. For patients at moderate risk, the correct management is aspirin unless there are specific contraindications. Patients at low risk should receive no thromboprophylaxis. The clinical risks of stroke and thromboprophylaxis on discharge from hospital were recorded. An extensive education programme on stroke prevention in atrial fibrillation was undertaken. Six months later a further 185 consecutive patients with atrial fibrillation were audited. Overall, a large proportion (306/370; 83%) of patients were at high risk of stroke. In the initial audit, antithrombotic management was correct in 89 patients (48%). In the follow up audit, antithrombotic management was correct in 135 patients (73%) (p < 0. 00001). If this improvement in management were extrapolated to all hospital patients in the United Kingdom, approximately 1400 strokes/year could be avoided. Despite broad consensus in recent publications, antithrombotic management of atrial fibrillation remains imperfect, with many patients exposed to unnecessarily high risk of stroke.