More than 40% of patients with a history of atrial fibrillation attend the emergency department inappropriately

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Patients with a previous diagnosis of atrial fibrillation who were assessed as attending the emergency department inappropriately did so because of fear, or as a result of advice from another person or self-monitoring, a study has found. Benedict Glover from Schulich Heart Center, Sunnybrook Health Sciences Centre (Toronto, Canada) presented the initial results of the Canadian AF-ED trial at the 24th Annual International AF Symposium (24–26 January, Boston, USA) during a late-breaking session.

The multicentre trial was conducted in Canada “to discover reasons why people with atrial fibrillation present inappropriately to emergency departments,” explained Glover. He added that the trial’s wider vision was “to try and develop a mechanism to stratify patients through other mechanisms so they don’t need to come to the emergency department with atrial fibrillation”.

According to Glover, inappropriate hospitalisations and emergency department visits among people with atrial fibrillation are “a huge financial problem”. The annual cost of atrial fibrillation in the USA is more than $6.7 billion, with “75% of this related to inpatient stay”. In Canada, smaller numbers are involved, but annual hospital costs of atrial fibrillation “are approximately $815 million”. Glover stated that the researchers’ aim was to “try to reduce the hospitalisations and emergency department attendance of patients with atrial fibrillation” in Canada.

The Canadian AF-ED trial was run with the Canadian Arrhythmia Network (CANet), which comprises 29 universities, each of which has two or three hospitals linked to it, 180 investigators and 24 industry partners. CANet’s 10-year goal aims to achieve “a 10% drop in sudden cardiac death, a 20% drop in hospitalisation and emergency department visits in patients with atrial fibrillation, and a 30% drop in hospitalisation and emergency department visits in patients with a history of syncope”.

The study was conducted over a 14-month period and coordinated at a centre in Ontario. If a patient with a known diagnosis of atrial fibrillation was admitted or attended the emergency department in any of the participating hospitals, they were asked to enrol in the study. They were asked a series of questions about why they had attended hospital. “We tried to work out whether it was an appropriate admission or attendance or not, and then what the outcomes of the attendance were, and whether there were any alternative strategies that may have worked better,” Glover explained.

Of the 356 patients recruited to the study, 71% attended because they had symptoms, such as palpitations, chest pain or shortness of breath. However, almost a third of patients did not have symptoms.

Almost 10% of the patients without symptoms attended because they were scared they were going to die, have a heart attack or have a stroke. Forty per cent of those patients who were scared they were going to have a stroke were not on oral anticoagulation even though their mean CHA2DS2-VASc score was 2. Eighteen per cent of patients without symptoms attended because they had been advised to, in a third of cases by a cardiologist, while 2% attended as a result of self-monitoring.

Patients assessed as having appropriate reasons to attend (n=204; 57%) required hospital admission or electrical or chemical cardioversion. Patients with symptoms were more likely to have an appropriate reason to visit the emergency department, as were those who had had multiple visits previously, and female patients.

The remaining patients (n=152; 43%) would have been better managed in another setting. These patients had received previous advice from a physician or a nurse, or were not on an oral anticoagulant and were worried they were going to have a stroke, or were scared.

When asked about alternative treatment strategies, most patients stated they would attend a rapid assessment outpatient atrial fibrillation clinic instead of the emergency department, while a significant number believed that smartphone applications may be of benefit.

This prompted the researchers to develop the VIRTUES platform (Virtual Integrated Reliable Transformative User-driven E-health System), which is now being tested in a small pilot study in patients with atrial fibrillation.

Wearable biosensor technology enables the patient to record their physiological data (such as ECG and blood pressure), which are transmitted via their cellphone to a central system linked to the hospital cardiology clinic and family practice clinic. The patient is then given feedback and advised what action to take instead of attending the emergency department.

Glover concluded by stating that he hoped the VIRTUES platform would help reduce emergency department attendances by patients with atrial fibrillation in the future. He also emphasised that it was important to ensure that patients with a CHA2DS2-VASc score of 2 are anticoagulated.

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