Primary Diagnosis Of Atrial Fibrillation Research Articles

Abstract 4113371: Impact of Protein-Energy Malnutrition on Atrial Fibrillation Outcomes: Insights from National Inpatient Sample (NIS) Study

Background: Atrial fibrillation (AF) is the most prevalent arrhythmia. Protein-energy malnutrition (PEM) has been implicated in various cardiovascular conditions, but the studies on its impact on AF outcomes are limited. This study aims to investigate the relationship between PEM and AF outcomes, since malnutrition could be a modifiable risk factor. Methods: Utilizing data from NIS (2017–2020), patients of age more than 18 years with a primary diagnosis of AF and a secondary diagnosis of PEM were identified. Data analysis was performed using STATA, employing the Student's t-test and Fischer's exact test to compare continuous variables and proportions, respectively. Adjusted odds ratios were calculated through multivariate regression analysis. The primary outcome was mortality, with secondary outcomes being mean length of stay (LOS), total hospitalization cost, major adverse cardiovascular events (MACE) and various in-hospital complications. Trends in mortality, LOS, and total cost of hospitalization were also assessed. Results: A total of 17,652,695 patients with AF were identified, of whom 1,452,695 (8.22%) had PEM. Patients with PEM had increased mortality (10.8% vs 4.52%, p<0.001), increased mean LOS (10.14 days vs 5.52 days, p<0.001) and a higher hospitalization cost ($121,721 vs 69,348, p<0.001). In AF patients with PEM compared to those without PEM, there were significantly increased rates of ACS (adjusted odds ratio, or aOR=1.21, 2.48 vs 1.85, p<0.001), pulmonary edema (aOR=1.37, 0.61 vs 0.44, p<0.001), CVA (aOR=1.45, 1.7 vs 1.04, p<0.001) acute respiratory failure (aOR=1.78, 20.27 vs 11.75, p<0.001), need of mechanical ventilation (aOR= 2.46, 9.36 vs 3.96, p<0.001), ARDS (aOR= 2.8, 0.55 vs 0.21, p<0.001), AKI (aOR=1.57, 35.45 vs 24.12, p<0.001), and septic shock (aOR= 3.32, 10.3 vs 3.24, p<0.001). There is an increased trend of mortality (10.77 in 2017 vs 11.87 in 2020, p<0.001), LOS (10.49 in 2017 vs 10.8 in 2020, p=0.04) and total hospitalization cost ($121,233 in 2017 vs $140,869 in 2020, p<0.001) in patients with AF and PEM. Conclusion: Our study highlights the association between PEM and adverse AF outcomes, revealing PEM as a significant predictor of increased mortality, morbidity, length of stay, and hospitalization costs. These results emphasize the necessity for targeted nutritional interventions in AF management. Further research and clinical strategies addressing nutritional deficits in AF populations are essential for improving outcomes.

Abstract 4135899: Large-Scale Investigation on the Outcomes of Atrial Fibrillation Ablation in Liver Cirrhosis Patients

Background: Catheter-based atrial fibrillation(AF) ablation is amongst the most commonly done EP procedures that have evolved over decades, improving patient outcomes and quality of life. Atrial fibrillation is seen in 5% of patients with cirrhosis and studies have shown AF in cirrhosis to be associated with increased mortality and adverse hospital outcomes. Aim: There is scarce literature on the outcomes of AF ablation in patients with cirrhosis. Our study aimed to study the safety and efficacy of catheter-based AF ablations in this population group and to ascertain if there is a difference compared to the general patient population. Methods: We used the Nationwide Inpatient Sample Database 2016-2020, the largest openly accessible inpatient healthcare database in the United States. Patients with a primary diagnosis of AF were identified using ICD-10 codes. We excluded patients with a secondary diagnosis of other arrhythmias, missing demographics, mortality, or age<18. The study population was divided into patients with and without cirrhosis. Information was collected regarding various patient demographic characteristics and comorbidities (comorbidity burden captured via Elixhauser Comorbidity Index). The primary endpoint was in-hospital mortality. The secondary endpoints were total complications, length of stay, and hospitalization charges. Results: A total of 23,905 patients underwent ablation, with 23,800 being non-cirrhotic, and only 105 presenting with cirrhosis. This signifies a relatively low proportion of cirrhotic patients undergoing ablation procedures, approximately 0.6% (105 out of a total of 17,600 cirrhotic patients). Additionally, the Elixhauser comorbidity index is significantly higher in cirrhotic patients (6.62) compared to non-cirrhotic patients (3.65) with a p-value <0.001, indicating a higher burden of comorbidities in the cirrhotic group. Patients with cirrhosis undergoing ablation procedures exhibit a notably higher risk of major bleeding compared to those without cirrhosis (14.3% vs. 4.06%, p-value = 0.02). Furthermore, the incidence of bleeding requiring transfusion is significantly elevated in cirrhotic patients (4.8%) in contrast to non-cirrhotic patients (0.2%) (p-value < 0.001). Conclusion: Although the risk of major bleeding is high, overall mortality and other complications are comparable to those without cirrhosis. We believe that this can be mitigated by carefully selecting the patients with cirrhosis for this procedure.

Evolving atrial fibrillation (AF) care in New Zealand (NZ): a nurse specialist-led clinic aiming to improve standardisation, equity, cost-effectiveness, and lifestyle modification in AF management

Abstract Background Management of atrial fibrillation (AF) in NZ is challenging and variable between regions. NZ has a diverse population with Māori and Pacific ethnic groups, in particular, facing significant difficulties with access to care and inequity in treatment. The integration of nurse specialists into the care of patients with AF is increasingly recognised and discussed in AF management, including the European Society of Cardiology (ESC) guidelines. This approach also allows emphasis on managing lifestyle factors, pivotal contributing factors in disease burden Objective This study assesses the efficacy of a nurse specialist-led AF clinic in a large regional centre in New Zealand. We look specifically at the standardisation of care, lifestyle management, the impact on health equity in managing AF, and the cost-effectiveness of these strategies. Methods A retrospective analysis of the first year of the clinic’s establishment was conducted reviewing the outcomes, attendance, and adherence to management guidelines. The clinic is running three days per week to follow up those presenting to the Emergency Department with a primary diagnosis of AF. After discharge, appointments are available within 48-72 hours of presentation. The clinics efficacy and ability to serve wider NZ populations will also be presented alongside a recently-published, similar initiative in Christchurch, NZ. Results Over the first year, 247 appointments were made (Median age 66, interquartile range 58-76, 48% male, 75% NZ European). 168 patients were established on a rhythm control strategy, with 20 directly referred for ablation, 26 receiving cardioversions, and the remainder established on anti-arrhythmic medication strategies. Lifestyle modifications were addressed with majority of these patients. Demographic data also highlighted once more, a need to focus on equity with only 17.4% of appointments attended by Māori and Pacific patients, lower than would be expected given population data and relative disease burden. Conclusions The Nurse Specialist-led AF clinic shows promising outcomes and is a positive step forward in AF management in this region of NZ. Incorporating ESC guidelines with emphasis on lifestyle factors and including rhythm control strategies to good effect. This clinic brings international standards to a local stage and throws a focus on our unique healthcare needs and an emphasis on equitable delivery of care. This clinic is scalable, effective, and an inclusive approach to AF care.

A 3-year retrospective exploration of predictors for cardiac arrest in atrial fibrillation

Abstract Background An increasing correlation between atrial fibrillation (AF) and a heightened risk of cardiac arrest is emerging. Yet, the specific predictors of cardiac arrest in hospitalized patients with AF remain unclear. Purpose This study aims to identify these predictors, providing essential insights for refined risk assessment and targeted clinical interventions. Methods Adult patients hospitalized between 2018 and 2020 with a primary diagnosis of AF with or without cardiac arrest were identified using the International Classification of Diseases, Tenth Revision (ICD-10) code. Demographics and comorbidities were recorded. Logistic regression was employed to identify predictors of increased cardiac arrest. Results In a study of 272,028 hospitalizations with AF, 2,352 patients suffered cardiac arrest, and 523 died during hospitalization. Factors associated with increased odds of cardiac arrest include heart failure (OR = 1.79, 95% CI: 1.60–2.00), cardiogenic shock (OR = 2.95, 95% CI: 2.35–3.71), history of coronary angioplasty or bypass (OR = 1.79, 95% CI: 1.59–2.02), chronic kidney disease (OR = 1.26, 95% CI: 1.12–1.42), end-stage kidney disease (OR = 2.34, 95% CI: 1.98–2.77), and septic shock (OR = 6.50, 95% CI: 4.80–8.80). Chronic obstructive pulmonary disease (COPD) and infection were associated with a 13% (OR = 1.13, 95% CI: 1.02–1.26) and 45% (OR = 1.45, 95% CI: 1.25–1.68) increase in odds for cardiac arrest, respectively. Increased age (OR = 0.99, 95% CI: 0.98–0.99) and female sex (OR = 0.83, 95% CI: 0.76–0.91) showed an inverse relation with cardiac arrest. Hypertension and obesity exhibited protective effects against cardiac arrest, with odds ratios of 0.85 (95% CI: 0.74–0.97) and 0.83 (95% CI: 0.75–0.93), respectively. Conclusion Our study underscores the intricate web of factors influencing cardiac arrest risk in AF patients. A personalized approach to risk assessment in the context of AF might be needed.

In-hospital outcomes among amyloidosis patients with atrial fibrillation: A propensity score-matched analysis.

The impact of atrial fibrillation (AF) among patients with amyloidosis on in-hospital outcomes is not well-established. We aimed to examine in-hospital outcomes among patients admitted with a primary diagnosis of AF with and without amyloidosis. We queried the Nationwide Readmissions Database to compare the in-hospital outcomes among AF patients with and without amyloidosis. Our study demonstrated that in-hospital all-cause mortality, adverse events, and 30-day readmission were comparable between the two groups. Patients with AF and concurrent amyloidosis did not have worse in-hospital outcomes than those with AF alone.

Differences in the Impact of Obesity and Bariatric Surgery on Patients Hospitalized for Atrial Flutter and Atrial Fibrillation: A Nationwide Analysis, 2016-2020.

The "obesity paradox" claims that although obesity is a risk factor for atrial fibrillation, obese patients have lower inpatient mortality when admitted due to atrial fibrillation. This study aims to analyze if the obesity paradox still holds true after weight loss from bariatric surgery. Methods: This study analyzed discharge data from the National Inpatient Sample, 2016-2020. Patients admitted due to atrial fibrillation or atrial flutter, with or without obesity, and with or without a past medical history of bariatric surgery were identified using ICD-10-CM and ICD-10-PCS codes. The primary outcome was mortality. Secondary outcomes included length of stay, resource utilization, necessity for endotracheal intubation, and necessity for cardioversion. STATA v.13 was used for univariate and multivariate analysis (StataCorp LLC, Texas, USA). Among 2,292,194 patients who had a primary diagnosis of atrial fibrillation or atrial flutter, 494,830 were obese and 25,940 had bariatric surgery. Mortality was not significantly different in post-bariatric surgery patients when compared to the general population (OR 0.76; 95% [CI 0.482-1.2; p=0.24]). Mortality was significantly lower in obese patients when compared to the general population (OR 0.646; 95% [CI 0.583-0.717; p<0.001]). Therefore, post-bariatric surgery patients had a higher mortality than obese patients when compared to the general population. Obese patients spent more days in the hospital (regression 0.219; 95% [CI 0.19-0.248, p<0.001]), had higher resource utilization (regression 3491.995; 95% [CI 2870.085-4113.905, p<0.001]), more cardioversions (OR 1.434; 95% [CI 1.404-1.465; p<0.001]), and no difference in endotracheal intubation rate (OR 1.02; 95% [CI 0.92-1.127; p=0.724]) when compared to the general population. Post-bariatric patients had no difference in length of stay (regression -0.053; 95% [CI -0.137-0.031; p=0.218]) and resource utilization (regression 577.297; 95% [CI -1069.801-2224.396; p=0.492]), fewer endotracheal intubations (OR 0.583; 95% [CI 0.343-0.99; p=0.046]), and more cardioversions (OR 1.223; 95% [CI 1.134-1.32; p<0.001]) when compared to the general population. Compared to the general population, post-bariatric patients had higher inpatient mortality than obese patients when admitted due to atrial fibrillation or atrial flutter. This research reinforces the presence of the obesity paradox following bariatric surgery with respect to mortality.

Rapid access nurse-led atrial fibrillation clinics reduce hospital readmissions

Abstract Background Atrial Fibrillation (AF) is the most common cardiac arrhythmia and in the UK accounts for about 1.5% of healthcare expenditure mainly through recurrent hospital admissions (1). The European Society of Cardiology 2020 AF guidelines (2) provides a clear framework of all the different components required to provide good patient-centred integrated AF management of which very little is done well within an emergency inpatient setting. Purpose We have developed a nurse led Rapid Access AF (RAAF) clinic aiming to prevent repeat admissions and improve patients overall AF care. Methods All patients discharged from our institution's emergency department (ED) or acute medical ward with a primary diagnosis of atrial fibrillation are suitable for the Rapid Access AF clinic. At the clinic the patients are given patient education, advise about risk factor modification, access to an "AF hotline" and a simple initial management plan should symptoms worsen with advise about when to attend the emergency department. Patients are then reviewed at a weekly multidisciplinary meeting with the local AF doctors where longer term strategies are made. The clinics have been operating now for 2 years and we have audited the 3 months from January to March 2022 with further follow up at 6 months. Results 41 out of 64 patients presenting to the emergency department with AF were admitted. However, whether in the ED or subsequent medical ward, treatment as a whole was very simple AF management, similar to that of outpatient care ( e.g. in ED Beta Blockers 34%, Digoxin 16%, oral Flecainide 5%, IV Amiodarone 12.5%, direct current cardioversion 1.5%, no clear AF treatment 16%, anticoagulation in patients with CHADSVASC 2+ 92%). 36 out of 64 patients were discharged to RAAF clinic and were seen on average 22 days post discharge. Readmission rates were 11% vs 32% at 30 days in patients discharged to RAAF compared to standard care and 14% vs 60% at 6 months. Conclusion Patients admitted to hospital with a primary diagnosis of AF are at high risk of early readmission. A rapid access AF clinic is effective at significantly reducing hospital readmission rates whilst also providing more holistic integrated AF management.

Long-term outcomes after hospitalization for atrial fibrillation or flutter.

Atrial fibrillation (AF) and flutter are common causes of hospitalizations but contemporary long-term outcomes following these episodes are uncertain. This study assessed outcomes up to 10 years after an acute AF or flutter hospitalization. Patients hospitalized acutely with a primary diagnosis of AF or flutter from 2008-17 from all public and most private hospitals in Australia and New Zealand were included. Kaplan-Meier methods and flexible parametric survival modelling were used to estimate survival and loss in life expectancy, respectively. Competing risk model accounting for death was used when estimating incidence of non-fatal outcomes. A total of 260 492 adults (mean age 70.5 ± 14.4 years, 49.6% female) were followed up for 1 068 009 person-years (PY), during which 69 167 died (incidence rate 6.5/100 PY) with 91.2% survival at 1 year, 72.7% at 5 years, and 55.2% at 10 years. Estimated loss in life expectancy was 2.6 years, or 16.8% of expected life expectancy. Re-hospitalizations for heart failure (2.9/100 PY), stroke (1.7/100 PY), and myocardial infarction (1.1/100 PY) were common with respective cumulative incidences of 16.8%, 11.0%, and 7.1% by 10 years. Re-hospitalization for AF or flutter occurred in 21.3% by 1 year, 35.3% by 5 years, and 41.2% by 10 years (11.6/100 PY). The cumulative incidence of patients undergoing catheter ablation of AF was 6.5% at 10 years (1.2/100 PY). Patients hospitalized for AF or flutter had high death rates with an average 2.6-year loss in life expectancy. Moreover, re-hospitalizations for AF or flutter and related outcomes such as heart failure and stroke were common with catheter ablation used infrequently for treatment, which warrant further actions.

Impact of Sarcoidosis on In-hospital Outcomes Among Patients with Atrial Fibrillation: A Nationwide Readmissions Database Analysis.

Sarcoidosis is a disease that involves multiple organs, including the cardiovascular system. While cardiac sarcoidosis has been increasingly recognized, the impact of sarcoidosis on atrial fibrillation (AF) is not well established. This study aimed to analyze the impact of sarcoidosis on in-hospital outcomes among patients who were admitted for a primary diagnosis of AF. Using the all-payer, nationally representative Nationwide Readmissions Database, our study included patients aged ≥18 years who were admitted for AF between 2017-2020. We stratified the cohort into two groups depending on the presence of sarcoidosis diagnosis. The in-hospital outcomes were assessed between the two groups via propensity score analysis. A total of 1031 (0.27%) AF patients with sarcoidosis and 387,380 (99.73%) AF patients without sarcoidosis were identified in our analysis. Our propensity score analysis of 1031 (50%) patients with AF and sarcoidosis and 1031 (50%) patients with AF but without sarcoidosis revealed comparable outcomes in early mortality (1.55% vs. 1.55%, P = 1.000), prolonged hospital stay (9.51% vs. 9.70%, P = .874), non-home discharge (7.95% vs. 9.89%, P = .108), and 30-day readmission (13.29% vs. 13.69%, P = .797) between the two groups. The cumulative cost of hospitalization was also similar in both groups ($12,632.25 vs. $12,532.63, P = .839). The in-hospital adverse event rates were comparable in both groups. Sarcoidosis is not a risk factor for poorer in-hospital outcomes following AF admission. These findings provide valuable insights into the effectiveness of the current guideline for AF management in patients with concomitant sarcoidosis and AF.

Impact of Various Atrial Fibrillation Treatment Strategies on Length of Stay in the Emergency Department and Early Complications-3 Years of a Single-Center Experience.

Atrial fibrillation (AF) is the most common arrhythmia presenting in emergency departments (EDs), vastly increasing mainly due to society's lifestyles leading to numerous comorbidities. Its management depends on many factors and is still not unified. Aims: The aim of this study was to compare different AF management strategies in the ED and to evaluate their influence on the length of stay (LOS) in the ED and their safety. We analyzed medical records over 3 years of data collection, including age, primary AF diagnosis, an attempt to restore sinus rhythm, complications, and length of stay. Patients were divided into three groups according to the treatment method received: only pharmacological cardioversion (MED), only electrical cardioversion (EC), and patients who received medications followed by electrical cardioversion (COMB). We included 599 individuals in the analysis with a median age of 71. The restoration of sinus rhythm and LOS were as follows: MED: 64.95%, 173 min; COMB: 87.91%, 295 min; SH: 92.40%, 180 min. The difference between the MED and EC strategies, as well as MED and COMB, was statistically significant (p < 0.001 in both). The total number of complications was 16, with a rate of 32.67%. The majority of them followed a drug administration, and the most common complication was bradycardia. Electrical cardioversion is a safe and effective treatment strategy in stable patients with AF in the ED. It is associated with a shortened LOS. Medication administration preceded the majority of complications.

Abstract 12441: Ambient Fine Particulate Matter Air Pollution but Not Ozone is Associated With Elevated Risk of All-Cause Hospitalization in Patients With a Prior Diagnosis of Atrial Fibrillation

Introduction: Short-term increases (days to weeks) in fine particulate matter (PM 2.5 ) air pollution are associated with atrial fibrillation (AF) episodes. We previously reported that PM 2.5 was not associated with severe AF measured as emergency or inpatient hospitalization for the primary diagnosis of AF. Mild AF, though, may influence all-cause hospitalizations. This study evaluated if short-term increases in PM 2.5 and ozone were associated with all-cause hospitalization at 11 Intermountain Health hospitals in patients with AF, and if this differed between wildfire (June-Oct.) and winter inversion (Nov.-March) seasons. Methods: Patients carrying an AF diagnosis (N=347,157) were evaluated for all-cause hospitalization and, secondarily, AF hospitalization (N=25,601) and first AF diagnosis (N=77,893). PM 2.5 levels were measured from January 1, 1999 to March 31, 2022 (ozone: 2006-2022) in subjects residing on Utah’s Wasatch Front. Using the case-crossover design that matched individual-level characteristics, Poisson regression also adjusted for weather variables. Results: Mean age was 72±15 years and 51.0% were female. Overall, PM 2.5 increases at a lag of 0 days, 1 day, 3-day moving average (mAvg) (days 0-2), and 7-day mAvg (days 0-6) were associated with all-cause hospitalization [respectively: odds ratio (OR)=1.010, 1.008, 1.011, 1.009 per +10 μg/m 3 ; p=0.0004, 0.006, 0.0004, 0.028]. Associations differed by seasons (Figure). Regressions entering both ozone and PM 2.5 mildly increased PM 2.5 ORs for all-cause hospitalization. PM 2.5 was not associated with first AF diagnosis. Increases in ozone were not associated with higher risk of any outcome. Conclusions: Short-term increases in PM 2.5 air pollution were associated with all-cause hospitalization in patients with a prior AF diagnosis. Lag structure varied for wildfire and inversion seasons, with greater effect sizes in wildfire season. Increases in ozone did not associate with elevated risk.

Abstract 15584: Artificial Intelligence-Guided Screening for Atrial Fibrillation Detection Among Patients With Different Socioeconomic Status

Introduction: Recently, an artificial intelligence (AI) algorithm was validated for identifying ECG signatures of atrial fibrillation (AF) risk during normal sinus rhythm. Traditionally, socioeconomically disadvantaged populations are less likely to receive novel or guideline-recommended treatments, and have high chronic disease burden, including cardiovascular diseases. There have also been concerns about new technologies creating a digital divide, worsening existing health disparities. Hypothesis: An AI algorithm will detect AF risk unequally across patients with different levels of social determinants of health (SDOH). Methods: The initial prospective, non-randomized, interventional study leveraged EHR and digital technologies to prospectively enroll 1004 patients with a broad range of AI-ECG risks of AF, who received continuous cardiac rhythm monitoring for up to 30 days. The Area Deprivation Index (ADI) was used as a composite measure of SDOH which is comprised of indicators spanning four domains: income, education, employment, and house quality. 904 intervention patients linked to the ADI data were matched to 904 real-world control patients derived from eligible but unenrolled patients. Those with ADI under 33% were defined as having better SODH; and patients with ADI above 33% were defined as having worse SODH. Results: Median age was 74 years and 38% were women. After matching, the intervention and control arms were balanced in all baseline characteristics, including HF, HTN, diabetes, stroke, CAD and ADI. A hazard ratio of 3.11 (P&lt;0.001) was computed when comparing intervention to control for primary AF diagnosis outcome. In patients with worse SDOH, the intervention increased AF detection from 2.6% to 8.8% (HR 3.63 [2.09, 6.32]); in the better SDOH, the intervention increased AF detection from 3.9% to 9.3% (2.41 [1.23, 4.74]). Conclusions: An AI-guided AF screening program increased the detection of AF in both patients with better or worse SDOH. The current study validates the use of AI in historically disadvantaged populations displaying the possibility for broad implementation with decreased possibility of perpetuating disparities.

Outcomes and Readmissions after Left Atrial Appendage Occlusion in Octogenarians: A Contemporary Analysis

Introduction and ObjectivesThe outcomes of left atrial appendage occlusion (LAAO) with the Watchman device in octogenarians are unknown as this population was underrepresented in major clinical trials. This study aims at examining the causes and outcomes of readmission after LAAO. DesignA retrospective cohort study based on the National Readmission Database in the United States. Settings and ParticipantPatients aged ≥80 years, admitted between January 2016 and December 2018, with the primary diagnosis of atrial fibrillation or flutter or who had LAAO were included in the study. Patients who died during index admission were excluded. MethodsWe used the National Readmission Database and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes to identify study participants. Data analysis was performed through Stata, version 17. Univariate and multivariate aggression analysis was used to adjust for confounders using Student t tests and χ2 tests. ResultsWe identified 491,329 patients on anticoagulation (AC) and 2030 patients who underwent LAA closure. Neither group differed regarding hypertension, previous myocardial infarction, or valvular heart disease. All-cause readmissions were lower in the LAAO group at 45 days (adjusted P < .01). All-cause readmissions at 45 and 90 days were similar in both groups. There was an increase in gastrointestinal bleeding (GIB) readmissions in the LAAO at 45 (P < .01), 90 (P < .01), and 180 (P < .01) days. There was no difference in GIB readmission between the 2 groups. There was no also difference in stroke or intracranial hemorrhage rates between the 2 groups throughout the follow-up period. Conclusion and ImplicationsIn octogenarians who received LAAO, the rate of GIB increased during the first 6 months after the procedure; however, it was not different from that of AC after that. Special attention should be given to the antithrombotic regimens after LAAO to avoid bleeding in this vulnerable patient population.

Implementation of an Atrial Fibrillation Decision Aid Care Pathway in the Emergency Department Reduces Atrial Fibrillation Hospitalizations.

A straightforward decision aid to guide disposition of atrial fibrillation (AF) patients in the emergency department (ED) was developed for use by ED providers. The implementation of this decision aid in the ED has not been studied. A pragmatic stepped-wedge cluster approach for analysis of retrospectively collected electronic health record data was used in which 5 hospitals were selected to commence the intervention at periodic intervals following an initial 1-year baseline assessment with 5 additional hospitals included in the comparison group (all in North Carolina). The primary end point of analysis was hospitalization rate. Hierarchical multivariable logistic regression analyses for admission as a function of the intervention while controlling for prespecified patient and hospital predictors were performed with clustering done at the hospital level. Between October 2017 and May 2020, a total of 11 458 patients (mean age, 71.4; 50.5% female) presented to 1 of the 10 hospitals with a primary diagnosis of AF. Absolute admission rate was reduced from 60.5% to 48.3% following the intervention (odds ratio, 0.83 [95% CI, 0.71-0.97]; P=0.016). After adjusting for covariates, the intervention was associated with a small increased rate of return to the ED for AF within 30 days of the initial presentation (1.6% to 2.7%; hazard ratio, 1.70 [95% CI, 1.26-2.31]; P<0.001). We demonstrate that implementation of a novel decision aid to guide disposition of patients primary diagnosis of AF presenting to the ED was associated with a reduced admission rate independent of patient and hospital factors. Use of the protocol was associated with a small but significant increase in rate of repeat presentations for AF at 30-day follow-up. Use of a decision aid such as the one described here represents an important tool to reduce unnecessary AF hospitalizations.

Impact of Frailty on Clinical Outcomes in Patients With Atrial Fibrillation Who Underwent Cardiac Ablation Using a Nationwide Database

This study aimed to assess the association between frailty and clinical outcomes in patients with atrial fibrillation (AF) who undergo catheter ablation. We conducted a retrospective cohort study using the National Inpatient Sample database from 2017 to 2019. Adult patients hospitalized with a primary diagnosis of AF who underwent catheter ablation were included. Frailty was assessed using the Hospital Frailty Risk Score. The primary outcome was the presence of any complication (vascular, cardiac, respiratory, neurologic, or infectious), and secondary outcomes were in-hospital mortality, length of hospital stay, and hospital charges. A total of 21,075 weighted hospitalizations were included, and 14% were classified as intermediate or great risk of frailty. Patients with intermediate (adjusted relative risk 2.86, 95% confidence interval 2.24 to 3.67) and great (adjusted relative risk 6.68, 95% confidence interval 3.77 to 11.84) risk of frailty were associated with a greater risk of any complication than that of the group at less risk. The in-hospital mortality rate was significantly higher among patients at intermediate risk than among those at less risk of frailty (2.6% vs 0.1%, p <0.001). Patients with great and intermediate risk had significantly longer hospital stays than did the group with less risk (median 14 vs 5 vs 2days, p <0.001), in addition to greater total charges (median $189,072 vs $161,598 vs $130,672, p <0.001), respectively. In conclusion, frailty was associated with a greater risk of poor short-term outcomes in patients with AF who underwent catheter ablation. The Hospital Frailty Risk Score is a useful tool for identifying patients at increased risk of adverse events and could aid in preoperative optimization and postoperative management.

Abstract #1407376: Hospital Outcomes of Atrial Fibrillation Admissions in Patients with Thyrotoxicosis: Nationwide Analysis

Studies have shown that thyrotoxicosis can trigger or cause Atrial Fibrillation (AF). Literature is lacking studies that describe the impact of thyrotoxicosis on AF admissions in terms of in-hospital mortality and other hospital outcomes. Patients admitted with a primary diagnosis of AF with or without a subsequent diagnosis of thyrotoxicosis were found in the National Inpatient Sample (NIS) Database from 2016 to 2019. Patients were separated into two groups: those with thyrotoxicosis and those without. Univariate and multivariate logistic regression analyses were used to control for frequent confounders and compare the risk of mortality and in-hospital outcomes between the two groups. A total of 1,329,950 patients were admitted with AF as a primary diagnosis during this period. Thyrotoxicosis was diagnosed in 24,754 patients (1.8%). The average age of the aggregate cohort was 70 years old, 52% were female, and 81% were a white race. The average length of stay (LOS) was 3.2 days and the average total hospital charges were 40,048 $. The total number of patients who died during the hospitalization was 11,574 patients. The previous history of thyrotoxicosis was not associated with an increased risk of in-hospital mortality (OR 0.91, 95% CI 0.63 –1.3, p=0.613) in AF hospitalizations. Thyrotoxicosis was not linked to an increased risk of cardiac outcomes like acute coronary syndrome (OR 0.88, 95% CI 0.73-1.06, p=0.2), cardiac arrest (OR 0.97, 95% CI 0.6-1.5, p=0.91), ventricular tachycardia (OR 0.91, 95% CI 0.76-1.09, p=0.327), ventricular fibrillation (OR 0.9, 95% CI 0.44-1.8, P=0.791) or hypertensive emergency (OR 0.66, 95% CI 0.34-1.27, P=0.22). The risk of acute respiratory failure (OR 1.14, 95% CI 0.97-1.35, p=0.103) or pulmonary edema (OR 1.11, 95% CI 0.82-1.5, p=0.492) was not statistically different between the two groups. This study strongly implies that thyrotoxicosis doesn’t impact patients admitted with atrial fibrillation in terms of in-hospital mortality and other hospital outcomes including acute coronary syndrome, cardiac arrest, ventricular tachycardia, ventricular fibrillation, or hypertensive emergency.

Initiation of oral anticoagulation in US older adults newly diagnosed with atrial fibrillation during hospitalization.

Atrial fibrillation is a common cause of stroke among older adults and is often first detected during hospitalization, given frequent use of cardiac telemetry. In a 20% national sample of Medicare fee-for-service beneficiaries, we identified patients aged 65-or-older newly diagnosed with atrial fibrillation while hospitalized in 2016. Our primary outcome was an oral anticoagulant claim within 7-days of discharge. Multivariable logistic regression analyses assessed relationships between anticoagulation initiation and thromboembolic and bleeding risk scores while controlling for demographics, frailty, comorbidities, and hospitalization characteristics. Among 38,379 older adults newly diagnosed with atrial fibrillation while hospitalized (mean age 78.2 [SD 8.4]; 51.8% female; 83.3% white), 36,633 (95.4%) had an indication for anticoagulation and 24.6% (9011) of those initiated an oral anticoagulant following discharge. Higher CHA2 DS2 -VASc score was associated with a small increase in oral anticoagulant initiation (predicted probability 20.5% [95% CI, 18.7%-22.3%] for scores <2 and 24.9% [CI, 24.4%-25.4%] for ≥4). Elevated HAS-BLED score was associated with a small decrease in probability of anticoagulant initiation (25.4% [CI, 24.4%-26.4%] for score <2 and 23.1% [CI, 22.5%-23.8%] for ≥3). Frailty was associated with decreased likelihood of oral anticoagulant initiation (24.7% [CI, 23.2%-26.2%] for non-frail and 18.1% [CI, 16.6%-19.6%] for moderately-severely frail). Anticoagulant initiation varied by primary reason for hospitalization, with predicted probability highest among patients with a primary diagnosis of atrial fibrillation (46.1% [CI, 45.0%-47.3%]) and lowest among those with non-cardiovascular conditions (13.8% [CI, 13.3%-14.3%]) and bleeds (3.6% [CI, 2.4%-4.8%]). Oral anticoagulant initiation is uncommon among older adults newly diagnosed with atrial fibrillation during hospitalization, even among patients hospitalized primarily for atrial fibrillation and patients with high thromboembolic risk. Clinicians should discuss risks and benefits of oral anticoagulants with all inpatients found to have atrial fibrillation.

Interhospital Variability in Utilization of Cardioversion for Atrial Fibrillation in the Emergency Department

The role for direct current cardioversion (DCCV) in the management of atrial fibrillation (AF) in the emergency department (ED) is unclear. Factors associated with DCCV in current practice are not well described, nor is the variation across patients and institutions. All ED encounters with a primary diagnosis of AF were identified from the Nationwide Emergency Department Sample from 2006 to 2017. The independent association of patient and hospital factors with use of DCCV was assessed using multivariable hierarchical logistic regression. The relative contributions of patient, hospital, and unmeasured hospital factors were assessed using reference effect measures methods. Among 1,280,914 visits to 3,264 EDs with primary diagnosis of AF, 31,422 patients (2.4%) underwent DCCV in the ED. History of stroke (odds ratio [OR] 0.14, 95% confidence interval [CI] 0.09 to 0.22, p <0.001) and dementia (OR 0.14, 95% CI 0.10 to 0.19, p <0.001) was associated with lowest odds of DCCV. Comparing patients more likely to receive DCCV (ninety-fifth percentile) with patients with median risk, the influence of unmeasured hospital factors (OR 14.13, 95% CI 12.55 to 16.09) exceeded the contributions of patient (OR 5.66, 95% CI 5.28 to 6.15) and measured hospital factors (OR 3.89, 95% CI 2.87 to 5.60). In conclusion, DCCV use in the ED varied widely across institutions. Disproportionately large unmeasured hospital variation suggests that presenting hospital is the most determinative factor in the use of DCCV for ED management of AF. Clarification is needed on best practices for management of AF in the ED, including the use of DCCV.

Prevalence of Cardio-Embolic Brain Complications in Permanent and Paroxysmal Atrial Fibrillation Patients.

Background: Atrial fibrillation (AF) is the most frequent of all cardiac arrhythmias, with an increasing prevalence in the last 20 years. Cardio-embolic brain complications (CEBC) related to AF often occur or recur, even following appropriate treatment. Method: We conducted a retrospective study and analyzed the presence of stroke, dementia, and Parkinson’s disease (PD) in both paroxysmal and permanent AF patients. The records of 1111 consecutive admitted patients with primary diagnosis of AF at the Municipal Emergency University Hospital, Timisoara, between 2015 and 2016 were examined. Statistical analysis was performed on the patients included in the study based on the inclusion and exclusion criteria. Results: A significant statistical difference was noted among the permanent AF group for stroke (48.75% vs. 26.74%, p < 0.001) and dementia (10.25% vs. 3.86%, p < 0.001) compared to paroxysmal AF patients. Permanent AF patients presented a higher risk of developing stroke, dementia, and PD compared to patients with paroxysmal AF. Meanwhile, male gender and an increase in age showed an increase in the odds of having cardio-embolic brain complications in patients with paroxysmal AF. Conclusion: Based on the results obtained, it can be concluded that the risk of cardio-cerebral embolic complications is greater in permanent AF patients compared to paroxysmal AF cases. Ischemic stroke and dementia are more frequent in the permanent AF group, but analyzing the data regarding the age of onset paroxysmal AF is critical due to the fact that it involves a younger population. Prompt diagnosis and treatment can help significantly in saving stroke patients.

Abstract 14227: Development of a Tool To Improve Risk Stratification of Patients With Atrial Fibrillation in the Emergency Department

Introduction: Currently, no tool exists to help emergency department (ED) physicians determine which patients with atrial fibrillation (AF) may be low risk for adverse outcomes and potential candidates for expedited discharge. Hypothesis: A simple decision aid can assess 90-day risk for a combined outcome of mortality, stroke, or re-presentation to the ED in AF patients. Methods: Through multi-disciplinary meetings, clinically relevant and easily attainable factors were selected to risk stratify AF patients in the ED, including: primary ED diagnosis (AF or other), age, AF symptom severity (Canadian Cardiovascular Society - Symptom of AF [CCS-SAF]), heart rate, blood pressure, and laboratory assessment. Logistic regression analyses were used to develop a scoring tool. Results: Over 15 months (Jan 2015 - Mar 2016), 935 consecutive patients presenting to the ED of an academic medical center hospital (University of North Carolina) with AF were included in the cohort. Ninety days from presentation, there were 275 (29.4%) adverse events. In multivariable analyses, 4 factors were identified which independently associated events among all patients with AF: non-AF primary ED diagnosis, age, heart rate, and severe AF symptoms (CCS-SAF 4). Using a scoring tool with these 4 factors (range 0-18), a score ≥ 14 predicted events with 72% accuracy. Including only the 223 patients with a primary diagnosis of AF, using a scoring tool with 3 factors (age ≥ 70, heart rate ≥ 105, severe AF symptoms) a score ≥ 10 (range 0-13) predicted events with 78% accuracy (25% sensitivity, 95% specificity). Conclusions: A simple risk stratification scoring tool may be useful to determine patient disposition for AF patients in the ED. In patients with a primary diagnosis of AF, the scoring tool was particularly useful (95% specific) in identifying patients unlikely to have an event. Further analyses of larger data sets are required for validation.