ORLANDO – An atrial fibrillation treatment pathway designed specifically to reduce the proportion of patients with this complaint who are admitted to the hospital from the emergency department was found remarkably effective in a pilot study presented at the annual International AF Symposium.
“In this single-center observational study, a multidisciplinary AF pathway was associated with fivefold reduction in admission rate and 2.5-fold reduction in length of stay for those who were admitted,” reported Jeremy N. Ruskin, MD.
Relative to many other countries, admission rates for AF in the United States are “extremely high,” according to Dr. Ruskin, director of the cardiac arrhythmia service at Massachusetts General Hospital, Boston. Citing 2013 figures from the Nationwide Emergency Department Sample (NEDS) database, rates ranged between 60% and 80% by geographic region with an average of about 66%. In contrast and as an example of lower rates elsewhere, fewer than 40% of AF patients with similar characteristics presenting at emergency departments in Ontario, Can., were admitted. Similarly low admission rates have been reported in Europe.
The AF pathway tested in the study at Mass General was developed through collaboration between electrophysiologists and emergency department physicians. It is suitable for patients presenting with a primary complaint of AF without concomitant diseases, such as sepsis or myocardial infarction. Patients were entered into this study after it was shown that AF was the chief complaint. The first step was to determine whether participants were best suited to a rhythm control or rate control strategy.
“The rhythm control group was anticoagulated and then underwent expedited cardioversion with TEE (transesophageal echocardiogram) if necessary. The rate control group was anticoagulated and then given appropriate pharmacologic therapy,” Dr. Ruskin explained. Once patients were on treatment, an electrophysiologist and an emergency room physician evaluated response. Stable patients were discharged; unstable patients were admitted.
In this nonrandomized observational study conducted over a 1-year period, 94 patients were managed with the AF pathway. Admissions and outcomes in this group were compared with 265 patients who received usual care.
Only 16% of those managed through the AF pathway were admitted versus 80% (P less than .001) in the usual care group. Among those admitted, length of stay was shorter in patients managed along the AF pathway relative to usual care (32 vs. 85 hours; P = .002). Dr. Ruskin also reported that both the cardioversion rate and the proportion of patients discharged on novel oral anticoagulation drugs were higher in the AF pathway group.
The reductions in hospital admissions would be expected to translate into large reductions in costs, particularly as follow-up showed no difference in return visits to the hospital between those entered into the AF pathway relative to those who received routine care, according to Dr. Ruskin. Emphasizing the cost burden of AF admissions, he noted that the estimated charges for the more than 300,000 AF admissions in U.S. hospitals in 2013 exceeded $7 billion.
Currently, there are no guidelines for managing AF in the emergency department, and there is wide variation in practice among centers, according to Dr. Ruskin. He provided data from the NEDS database demonstrating highly significant variations in rates of admission by geographic region (for example, rates were more than 10% higher in the northeast vs. the west) and hospital type (for example, rates were twice as high in metropolitan than nonmetropolitan hospitals).
In the NEDS database, various patient characteristics were associated with increased odds ratios for admission. These included hypertension (OR, 2.3), valvular disease (OR, 3.6), and congestive heart failure (OR, 3.7). However, Dr. Ruskin indicated that patients with these or other characteristics associated with increased likelihood of admission, such as older age, have better outcomes with hospitalization.
The data from this initial observational study were recently published (Am J Cardiol. 2016 Jul 1;118[1]:64-71), and a larger prospective study with this AF pathway is already underway at both Mass General and at Brigham and Women’s Hospital, Boston. If the data confirm that AF admissions can be safely reduced through this pathway, Dr. Ruskin anticipates that implementation will be adopted at other hospitals in the Harvard system.
Dr. Ruskin reported financial relationships with Cardiome, Daiichi Sankyo, Gilead, InCarda Therapeutics, InfoBionic, Laguna Medical, Medtronic, Pfizer, and Portola.