Coordination of Atrial Fibrillation Management in the Emergency Department and Outpatient Settings
Main Article Content
Abstract
Historically, a majority of patients presenting to the Emergency Department (ED) with a primary diagnosis of atrial fibrillation (AF) have been admitted to an inpatient unit. Treatment protocols for AF management in the ED have been shown to reduce the need for inpatient admissions and improve adherence to treatment guidelines for the administration of oral anticoagulation (OAC) therapy. Establishment of outpatient follow-up is a necessary part of discharging patients with AF from the ED. Follow-up planning can present a challenge for clinicians in the ED setting, as many patients who present to the ED with AF do not have an established cardiologist or cardiac electrophysiologist. Inability to arrange timely outpatient follow-up can therefore represent a barrier to discharge from the ED. The presence of outpatient clinics dedicated to AF management can help clinicians in the ED to manage patients with AF more efficiently. In this review, we describe the components of dedicated AF clinics. We also describe aspects of patient care that can be improved through implementation of dedicated AF outpatient clinics. These improvements include enhanced adherence with OAC therapy, reduced hospital re-admissions, improved patient outcomes, and reduced healthcare costs.
Article Details
How to Cite
SHARIF, Zain; PTASZEK, Leon M.
Coordination of Atrial Fibrillation Management in the Emergency Department and Outpatient Settings.
Medical Research Archives, [S.l.], v. 11, n. 7.1, july 2023.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/4056>. Date accessed: 15 may 2024.
doi: https://doi.org/10.18103/mra.v11i7.1.4056.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
1. Jackson SL, Tong X, Yin X, et al. Emergency department, hospital inpatient, and mortality burden of atrial fibrillation in the United States, 2006 to 2014. Am J Cardiol. 2017;120:1966–73.
2. Rozen G, Hosseini SM, Kaadan MI, et al. Emergency department visits for atrial fibrillation in the United States: Trends in admission rates and economic burden from 2007 to 2014. J Am Heart Assoc. 2018;121:1187–91.
3. McDonald AJ, Pelletier AJ, Ellinor PT, et al. Increasing US emergency department visit rates and subsequent hospital admissions for atrial fibrillation from 1993 to 2004. Ann Emerg Med. 2008;51:58–65.
4. Kim MH, Johnston SS, Chu BC, et al. Estimation of total incremental health care costs in patients with atrial fibrillation in the United States. Circ Cardiovasc Qual Outcomes. 2011;4:313–20.
5. Coyne KS, Paramore C, Grandy S, et al. Assessing the direct costs of treating nonvalvular atrial fibrillation in the United States. Value Health. 2016;9:348–56.
6. Lin MP, Ma J, Weissman JS, et al. Hospital level variation and predictors of admission after ED visits for atrial fibrillation: 2006 to 2011. Am J Emerg Med. 2016;34:2094–100.
7. DeMeester S, Hess RA, Hubbard B, et al. Implementation of a novel algorithm to decrease unnecessary hospitalizations in patients presenting to a community emergency department with atrial fibrillation. Acad Emerg Med. 2018;25:641–49.
8. Koenig BO, Ross MA, Jackson RE. An emergency department observation unit protocol for acute-onset atrial fibrillation is feasible. Ann Emerg Med. 2002;39:374–81.
9. Stiell IG, Clement CM, Symington C, et al. Emergency department use of intravenous procainamide for patients with acute atrial fibrillation or flutter. Acad Emerg Med. 2007;14:1158–64.
10. Decker WW, Smars PA, Vaidyanathan L, et al. A prospective, randomized trial of an emergency department observation unit for acute onset atrial fibrillation. Ann Emerg Med. 2008;52:322–8.
11. Burton JH, Vinson DR, Drummond K, et al. Electrical cardioversion of emergency department patients with atrial fibrillation. Ann Emerg Med. 2004;44:20–30.
12. Stiell IG, Clement CM, Perry JJ, et al. Association of the Ottawa Aggressive Protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter. CJEM. 2010;12:181–91.
13. Scheuermeyer FX, Andolfatto G, Christenson J, et al. A multicenter randomized trial to evaluate a chemical-first or electrical-first cardioversion strategy for patients with uncomplicated acute atrial fibrillation. Acad Emerg Med. 2019;26:969–81.
14. Martin A, Coll-Vinent B, Suero C, et al. Benefits of rhythm control and rate control in recent-onset atrial fibrillation: The HERMES-AF study. Acad Emerg Med. 2019;26:1034–43.
15. Ptaszek LM, White B, Lubitz SA, et al. Effect of a multidisciplinary approach for the management of patients with atrial fibrillation in the emergency department on hospital admission rate and length of stay. Am J Cardiol. 2016;118:64–71.
16. Ptaszek LM, Baugh CW, Lubitz SA, et al. Impact of a multidisciplinary treatment pathway for atrial fibrillation in the emergency department on hospital admissions and length of stay: results of a multi-center study. J Am Heart Assoc. 2019;8:e012656.
17. Stiell IG, Scheuermeyer FX, Vadeboncoeur A, et al. CAEP acute atrial fibrillation/flutter best practices checklist. CJEM. 2018;20:334–42.
18. Gehi AK, Deyo Z, Mendys P, et al. Novel care pathway for patients presenting to the emergency department with atrial fibrillation. Circ Cardiovasc Qual Outcomes. 2018;11:e004129.
19. Vinson DR, Warton EM, Mark DG, et al. Thromboprophylaxis for patients with high-risk atrial fibrillation and flutter discharged from the emergency department. West J
Emerg Med. 2018;19:346–60.
20. Rezazadeh S, Chew DS, Miller RJH, et al. Effects of a reminder to initiate oral anticoagulation in patients with atrial fibrillation/atrial flutter discharged from the emergency department: REMINDER study. CJEM. 2018;20:841–9.
21. Barbic D, DeWitt C, Harris D, et al. Implementation of an emergency department atrial fibrillation and flutter pathway improves rates of appropriate anticoagulation, reduces length of stay and thirty-day revisit rates for congestive heart failure. CJEM. 2018;20:392–400.
22. Writing Group Members, January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines and the Heart Rhythm Society. Heart Rhythm. 2019;2019(16):e66–93.
23. Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). EHJ 2020 42, 373-498.
24. Atzema CL, Yu B, Ivers NM, et al. Predictors of obtaining follow-up care in the province of Ontario, Canada, following a new diagnosis of atrial fibrillation, heart failure, and hypertension in the emergency department. CJEM. 2018;20:377–91.
25. Abadie BQ, Hansen B, Walker J, et al. An atrial fibrillation transitions of care clinic improves atrial fibrillation quality metrics. JACC Clin Electrophysiol. 2020;6:45–52.
26. Carter L, Gardner M, Magee K, et al. An integrated management approach to atrial fibrillation. J Am Heart Assoc. 2016;5:e002950.
27. Saraswat MK, Carter L, Berrigan P, et al. Integrated management approach to atrial fibrillation care: a cost utility analysis. Can J Cardiol. 2019;35:1142–8.
28. Abadie BQ, Hansen B, Walker J, et al. An atrial fibrillation transitions of care clinic improves atrial fibrillation quality metrics. JACC Clin Electrophysiol. 2020;6:45–52.
29. Conti A, Canuti E, Mariannini D, et al. Clinical management of atrial fibrillation: early interventions, observation, and structured follow-up reduce hospitalizations. AJEM. 2012;30(9), 1962-1969.
30. Gehi AK, Deyo Z, Mendys P, et al. Novel Care Pathway for Patients Presenting to the Emergency Department with Atrial Fibrillation. Circ Cardiovasc Qual Outcomes. 2018;11:e004129.
31. Hendriks JML, de Wit R, Crijns HJGM, et al. Nurse-led care vs. usual care for patients with atrial fibrillation: results of a randomized trial of integrated chronic care vs. routine clinical care in ambulatory patients with atrial fibrillation. Eur Heart J. 2012;33:2692–2699.
32. Hendriks JML, Vrijhoef HJM, Crijns HJGM, et al. The effect of a nurse-led integrated chronic care approach on quality of life in patients with atrial fibrillation. Europace. 2014;16:491–9.
33. Stewart S, Ball J, Horowitz JD, et al. Standard versus atrial fibrillation-specific management strategy (SAFETY) to reduce recurrent admission and prolong survival: Pragmatic, multicentre, randomised controlled trial. Lancet. 2015;385:775–84.
34. Zimetbaum P, Reynold MR, Ho KL, et al. Impact of a practice guideline for patients with atrial fibrillation on medical resource utilization and costs. The American Journal of Cardiology. 2003, 92(6); 677-681.
35. Contreras JP, Hong KN, Castillo J, et al. Anticoagulation in patients with atrial fibrillation and heart failure: insights from the NCDR PINNACLE-AF registry. Clin Cardiol, 42 (2019), pp. 339-345
36. Lip GY, Nieuwlaat R, Pisters R, et al. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor‐based approach: the euro heart survey on atrial fibrillation. Chest. 2010; 137:263–272.
37. Staerk L, Wang B, Preis SR, et al. Lifetime risk of atrial . fibrillation according to optimal, borderline, or elevated levels of risk factors: . cohort study based on longitudinal data from the Framingham Heart Study. BMJ. 2018;361:k1453.
38. Burdett P, Lip GYH. Atrial fibrillation in the UK: predicting costs of an emerging epidemic recognizing and forecasting the cost drivers of atrial fibrillation-related costs. EHJ-QCC. 2022, 187-194.
39. Woods T-J, Ngo L, Speck P, et al. Thirty-Day Unplanned Readmissions Following Hospitalisation for Atrial Fibrillation in Australia and New Zealand. Heart Lung Circ. 2022 Jul;31(7):944-953.
40. Tripathi B, Atti V, Kumar V, et al. Outcomes and Resource Utilization Associated with Readmissions After Atrial Fibrillation Hospitalizations. JAHA 2019; 8(19):e013026.
41. Pluymaekers NAH, Hermans ANL, Van der Velden RMJ, et al. Implementation of an on-demand app-based heart rate and rhythm monitoring infrastructure for the management of atrial fibrillation through teleconsultation: TeleCheck-AF. Europace 2021 8;23(3):345-352.
2. Rozen G, Hosseini SM, Kaadan MI, et al. Emergency department visits for atrial fibrillation in the United States: Trends in admission rates and economic burden from 2007 to 2014. J Am Heart Assoc. 2018;121:1187–91.
3. McDonald AJ, Pelletier AJ, Ellinor PT, et al. Increasing US emergency department visit rates and subsequent hospital admissions for atrial fibrillation from 1993 to 2004. Ann Emerg Med. 2008;51:58–65.
4. Kim MH, Johnston SS, Chu BC, et al. Estimation of total incremental health care costs in patients with atrial fibrillation in the United States. Circ Cardiovasc Qual Outcomes. 2011;4:313–20.
5. Coyne KS, Paramore C, Grandy S, et al. Assessing the direct costs of treating nonvalvular atrial fibrillation in the United States. Value Health. 2016;9:348–56.
6. Lin MP, Ma J, Weissman JS, et al. Hospital level variation and predictors of admission after ED visits for atrial fibrillation: 2006 to 2011. Am J Emerg Med. 2016;34:2094–100.
7. DeMeester S, Hess RA, Hubbard B, et al. Implementation of a novel algorithm to decrease unnecessary hospitalizations in patients presenting to a community emergency department with atrial fibrillation. Acad Emerg Med. 2018;25:641–49.
8. Koenig BO, Ross MA, Jackson RE. An emergency department observation unit protocol for acute-onset atrial fibrillation is feasible. Ann Emerg Med. 2002;39:374–81.
9. Stiell IG, Clement CM, Symington C, et al. Emergency department use of intravenous procainamide for patients with acute atrial fibrillation or flutter. Acad Emerg Med. 2007;14:1158–64.
10. Decker WW, Smars PA, Vaidyanathan L, et al. A prospective, randomized trial of an emergency department observation unit for acute onset atrial fibrillation. Ann Emerg Med. 2008;52:322–8.
11. Burton JH, Vinson DR, Drummond K, et al. Electrical cardioversion of emergency department patients with atrial fibrillation. Ann Emerg Med. 2004;44:20–30.
12. Stiell IG, Clement CM, Perry JJ, et al. Association of the Ottawa Aggressive Protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter. CJEM. 2010;12:181–91.
13. Scheuermeyer FX, Andolfatto G, Christenson J, et al. A multicenter randomized trial to evaluate a chemical-first or electrical-first cardioversion strategy for patients with uncomplicated acute atrial fibrillation. Acad Emerg Med. 2019;26:969–81.
14. Martin A, Coll-Vinent B, Suero C, et al. Benefits of rhythm control and rate control in recent-onset atrial fibrillation: The HERMES-AF study. Acad Emerg Med. 2019;26:1034–43.
15. Ptaszek LM, White B, Lubitz SA, et al. Effect of a multidisciplinary approach for the management of patients with atrial fibrillation in the emergency department on hospital admission rate and length of stay. Am J Cardiol. 2016;118:64–71.
16. Ptaszek LM, Baugh CW, Lubitz SA, et al. Impact of a multidisciplinary treatment pathway for atrial fibrillation in the emergency department on hospital admissions and length of stay: results of a multi-center study. J Am Heart Assoc. 2019;8:e012656.
17. Stiell IG, Scheuermeyer FX, Vadeboncoeur A, et al. CAEP acute atrial fibrillation/flutter best practices checklist. CJEM. 2018;20:334–42.
18. Gehi AK, Deyo Z, Mendys P, et al. Novel care pathway for patients presenting to the emergency department with atrial fibrillation. Circ Cardiovasc Qual Outcomes. 2018;11:e004129.
19. Vinson DR, Warton EM, Mark DG, et al. Thromboprophylaxis for patients with high-risk atrial fibrillation and flutter discharged from the emergency department. West J
Emerg Med. 2018;19:346–60.
20. Rezazadeh S, Chew DS, Miller RJH, et al. Effects of a reminder to initiate oral anticoagulation in patients with atrial fibrillation/atrial flutter discharged from the emergency department: REMINDER study. CJEM. 2018;20:841–9.
21. Barbic D, DeWitt C, Harris D, et al. Implementation of an emergency department atrial fibrillation and flutter pathway improves rates of appropriate anticoagulation, reduces length of stay and thirty-day revisit rates for congestive heart failure. CJEM. 2018;20:392–400.
22. Writing Group Members, January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines and the Heart Rhythm Society. Heart Rhythm. 2019;2019(16):e66–93.
23. Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). EHJ 2020 42, 373-498.
24. Atzema CL, Yu B, Ivers NM, et al. Predictors of obtaining follow-up care in the province of Ontario, Canada, following a new diagnosis of atrial fibrillation, heart failure, and hypertension in the emergency department. CJEM. 2018;20:377–91.
25. Abadie BQ, Hansen B, Walker J, et al. An atrial fibrillation transitions of care clinic improves atrial fibrillation quality metrics. JACC Clin Electrophysiol. 2020;6:45–52.
26. Carter L, Gardner M, Magee K, et al. An integrated management approach to atrial fibrillation. J Am Heart Assoc. 2016;5:e002950.
27. Saraswat MK, Carter L, Berrigan P, et al. Integrated management approach to atrial fibrillation care: a cost utility analysis. Can J Cardiol. 2019;35:1142–8.
28. Abadie BQ, Hansen B, Walker J, et al. An atrial fibrillation transitions of care clinic improves atrial fibrillation quality metrics. JACC Clin Electrophysiol. 2020;6:45–52.
29. Conti A, Canuti E, Mariannini D, et al. Clinical management of atrial fibrillation: early interventions, observation, and structured follow-up reduce hospitalizations. AJEM. 2012;30(9), 1962-1969.
30. Gehi AK, Deyo Z, Mendys P, et al. Novel Care Pathway for Patients Presenting to the Emergency Department with Atrial Fibrillation. Circ Cardiovasc Qual Outcomes. 2018;11:e004129.
31. Hendriks JML, de Wit R, Crijns HJGM, et al. Nurse-led care vs. usual care for patients with atrial fibrillation: results of a randomized trial of integrated chronic care vs. routine clinical care in ambulatory patients with atrial fibrillation. Eur Heart J. 2012;33:2692–2699.
32. Hendriks JML, Vrijhoef HJM, Crijns HJGM, et al. The effect of a nurse-led integrated chronic care approach on quality of life in patients with atrial fibrillation. Europace. 2014;16:491–9.
33. Stewart S, Ball J, Horowitz JD, et al. Standard versus atrial fibrillation-specific management strategy (SAFETY) to reduce recurrent admission and prolong survival: Pragmatic, multicentre, randomised controlled trial. Lancet. 2015;385:775–84.
34. Zimetbaum P, Reynold MR, Ho KL, et al. Impact of a practice guideline for patients with atrial fibrillation on medical resource utilization and costs. The American Journal of Cardiology. 2003, 92(6); 677-681.
35. Contreras JP, Hong KN, Castillo J, et al. Anticoagulation in patients with atrial fibrillation and heart failure: insights from the NCDR PINNACLE-AF registry. Clin Cardiol, 42 (2019), pp. 339-345
36. Lip GY, Nieuwlaat R, Pisters R, et al. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor‐based approach: the euro heart survey on atrial fibrillation. Chest. 2010; 137:263–272.
37. Staerk L, Wang B, Preis SR, et al. Lifetime risk of atrial . fibrillation according to optimal, borderline, or elevated levels of risk factors: . cohort study based on longitudinal data from the Framingham Heart Study. BMJ. 2018;361:k1453.
38. Burdett P, Lip GYH. Atrial fibrillation in the UK: predicting costs of an emerging epidemic recognizing and forecasting the cost drivers of atrial fibrillation-related costs. EHJ-QCC. 2022, 187-194.
39. Woods T-J, Ngo L, Speck P, et al. Thirty-Day Unplanned Readmissions Following Hospitalisation for Atrial Fibrillation in Australia and New Zealand. Heart Lung Circ. 2022 Jul;31(7):944-953.
40. Tripathi B, Atti V, Kumar V, et al. Outcomes and Resource Utilization Associated with Readmissions After Atrial Fibrillation Hospitalizations. JAHA 2019; 8(19):e013026.
41. Pluymaekers NAH, Hermans ANL, Van der Velden RMJ, et al. Implementation of an on-demand app-based heart rate and rhythm monitoring infrastructure for the management of atrial fibrillation through teleconsultation: TeleCheck-AF. Europace 2021 8;23(3):345-352.