Primary Diagnosis Of Atrial Fibrillation Research Articles

Optimizing healthcare utilization in atrial fibrillation complicated by cancer

Abstract Funding Acknowledgements Type of funding sources: None. Background Previous studies have shown that atrial fibrillation is a significant cause of healthcare utilization and readmissions. Cancer is also an extenuating burden and has been shown to complicate management strategies, inducing higher utilization.1 We aimed to discover the impact of atrial fibrillation in the setting of non-metastatic cancer and managements which optimize healthcare consumption. Methods We queried the 2016-2018 National Readmission Database (NRD) for adults with a primary atrial fibrillation diagnosis and a secondary non-metastatic cancer diagnosis using ICD-10-CM codes and the Elixhauser Comorbidity Software. Patients were included if the admission was between January and November. Patients were excluded if the index admission was in December (to allow for 30-day readmissions), included cardiac arrest, cardiogenic shock, or they previously had a cardiac pacemaker inserted. Survey weighting methodology was used in accordance with NRD best practices. Propensity score matching was implemented to assess the average treatment effect on the treated (ATET) using a percutaneous loop recorder. Patients were matched on socioeconomic and hospital characteristics, in-hospital medical or procedural complications, and comorbidities. Results From 2016-2018, 21,922 patients met the inclusion criteria for index admissions. The average index admission age was 74.7 years, and 47.3% were female. Length of stay for index admissions was not significantly different between the two groups (4.33 days versus 4.90 days; p = 0.496). In-hospital mortality occurred in 1.65% of admissions, none of which had undergone insertion of a loop recorder. Overall, 18.8% of index admissions were readmitted within 30-days. The readmission rate for patients receiving a loop recorder was 5.5%, compared to 18.9% in the control group. Propensity score matching revealed a 70.2% reduction in 30-day readmissions (OR, 0.099 to 0.907; p = 0.033) for patients discharged with a loop recorder. Patients with a loop recorder have no significant difference in length of stay (5.72 days versus 5.79 days; p = 0.944) when readmitted. Conclusions Patients admitted for atrial fibrillation complicated by cancer had significantly lower readmission rates when discharged with a loop recorder. This phenomenon may be related to the increased ambulatory monitoring and early intervention ability. In the absence of increased length of stays or in-patient mortality, the decrease in healthcare utilization may be of significant benefit. The mechanisms involving factors between atrial fibrillation and cancer are yet to be understood.2,3 Further studies are needed to confirm these findings and evaluate the mechanism by which readmission rates are decreased.

PO-701-01 NINE MONTH READMISSION RATES AND CLINICAL OUTCOMES OF ANTICOAGULATION VERSUS WATCHMAN DEVICE IN OCTOGENARIANS

Atrial Fibrillation (AF), the most common arrhythmia in older adults, is fraught with an increased risk of stroke. Studies which have demonstrated non-inferiority of Left atrial appendage occlusion (LAAO) with a watchman device compared to oral anticoagulation for stroke risk reduction in AF did not include patients greater than 80 years of age, making it difficult to generalize these results to this population. This study compared nine month clinical outcomes in patients aged 80 and above who had LAAO with a watchman device to those who were only on oral anticoagulation for AF. This was a retrospective cohort study using samples from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project NRD. We included patients aged 80 and above admitted between January 2016 and December 2018 with a primary diagnosis of AF or atrial flutter who had undergone LAAO with a watchman device or were only on oral anticoagulation. Clinical outcomes were assessed at 9 months after index admission. Primary outcomes were all-cause readmissions, readmissions due to intracranial hemorrhage (ICH), stroke or TIA. Secondary outcomes were readmissions due to gastrointestinal (GI) bleeding, hematuria and need for RBC transfusions, colonoscopy or upper endoscopy. Analysis was done with STATA 17 (Stata Statistical Software: Release 17. College Station, TX: StataCorp LLC). Owing to differences in baseline characteristics, an adjusted analysis for the baseline characteristics was included. Our study consisted of a total of 491,329 patients in the anticoagulation group and 2030 patients in the watchman group. Baseline characteristics are depicted in table 1. At 9 month follow up, patients in the watchman group had a significantly higher frequency of all-cause readmissions compared to the anticoagulation group (8% vs 6%, P value 0.02, adjusted Odds Ratio 1.3, 95% CI 1.02 - 1.6). There were no significant differences in secondary outcomes between both groups as depicted in table 2. All-cause readmissions were significantly increased in the watchman group at 9 month follow-up despite no significant differences found in ICH, stroke and GI bleeding related readmissions between both groups. More studies are needed to support these findings.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Abstract 12: Oral Anticoagulant Prescribing For Older Adults Newly Diagnosed With Atrial Fibrillation During Hospitalization

Background: Oral anticoagulants are indicated in patients with atrial fibrillation (AF) at elevated thromboembolic risk. AF is often diagnosed during hospitalization, yet little is known about rates of anticoagulant initiation in this setting. Methods: We examined a 20% national sample of Medicare fee-for-service beneficiaries enrolled in Part D, aged > 65 years, who were hospitalized in 2016, and who received a new diagnosis of AF. The primary outcome was anticoagulant claim within 7 days of discharge home. We used multivariable logistic regression and post-estimation predicted probabilities to identify predictors of discharge with an anticoagulant, hypothesizing that thromboembolic risk, bleeding risk, and frailty would independently influence anticoagulant initiation. Results: Among 31,889 patients diagnosed with AF while hospitalized (mean age, 78; 52% female; 84% white; 95% CHA 2 DS 2 -VASc ≥2; 84% HAS-BLED ≥2; 37% frail), one-quarter initiated an anticoagulant following discharge. In multivariable models, rates of anticoagulant initiation varied by primary reason for hospitalization, with the highest predicted probability of initiation among those with a primary diagnosis of AF (46.3%; 95% CI 45.1-47.5), followed by cardiac surgery (42.8%; 39.6-46.0), other cardiovascular conditions (25.1%; 24.3-26.0), non-cardiac diagnoses (18.6%; 17.3-19.9), and bleeds (3.6%; 2.3-5.0). Higher CHA 2 DS 2 -VASc score was associated with a small increase in anticoagulant initiation (predicted probability 19.8% [15.4-24.2] for CHA 2 DS 2 -VASc <2 and 25.2% [24.7-25.7] for ≥4). Higher HAS-BLED score was associated with a small decrease (25.7% [24.6-26.8] for HAS-BLED <2 and 23.4% [22.7-24.1] for ≥3). Increased frailty was associated with decreased likelihood of anticoagulant initiation, with robust and moderately-severely frail patients having predicted probabilities of 25.0% (23.3-26.6) and 17.6% (15.9-19.2) respectively. Discussion: Anticoagulant initiation is uncommon among older adults newly diagnosed with AF during hospitalization, even among those hospitalized primarily for AF and those with high thromboembolic risk. Providers should carefully weigh risks and benefits of anticoagulants with all inpatients found to have AF.

The impact of hospital teaching status in atrial fibrillation hospital admission outcomes: a national inpatient analysis in the united states

Abstract Background Teaching hospitals are are usually larger and have a higher level of complexity. Admissions for atrial fibrillation are commonly encountered by residents and fellows and they carry a hight cost, morbidity and mortality. Purpose Our aim is to do a retrospective analysis of the National Impatient Sample (NIS) from 2016 to 2018 and determine the impact of the hospital teaching status and rural Vs urban location in the atrial fibrillation admission outcomes. Methods We combined the NIS from 2016–2018. A primary diagnosis of atrial fibrillation was identified identified. We stratified the admissions based on the hospital teaching status. We defined as primary outcomes the length of stay (LOS), in hospital mortality and total charges/cost per admission. The secondary outcomes were the rates acute kidney injury (AKI), acute blood loss anemia (ABLA) and embolic stroke (ES). We used the Charlson comorbidity index. We used univariate and multivariate linear regressions for the continuous outcomes and logistic regressions for the binary outcomes. Results We identified 981,739 admissions with a primary diagnosis of atrial fibrillation; 513,914 (47%) were female patients, the average age was 70.5 years. In the teaching hospitals, the LOS was 0.3 days longer [95% CI: 0.22–0.37]; p=0.000 and the total hospital charges were higher (8406.32 dollar more per admission [95% CI: 6510.89–10301.76]; p=0.000); there was no difference in mortality compared to the non-teaching institutions (OR 1.03 [95% CI: 0.87–1.21]; p=0.628). In teaching hospitals, the rates of AKI, ABLA and ES were higher (OR 1.2, 95% CI [1.12–1.27]; p=0.000), (OR 1.29, 95% CI [1.09–1.53]; p=0.003) and (OR 1.72, 95% CI [1.11–2.66]; p=0.014)respectively. In a subgroup analysis comparing urban teaching hospitals Vs urban non-teaching Vs rural non-teaching hospitals, we found that the primary outcomes were similar than the above but the results in the secondary outcomes were driven mainly by a marked difference between rural and urban institutions regardless of teaching status, which makes us think that there might be under diagnosis of atrial fibrillation related complications in lower complexity rural hospitals. The difference in costs per admission was not as high when comparing urban teaching with non-teaching hospitals (5103.96 dollar higher, 95% [CI: 3008.70–7199.23]; p=0.000). Conclusion Amongst admissions for atrial fibrillation, the total cost per admission was higher in teaching hospitals which was concordant with a longer LOS. Although our results show higher rates of AKI, ABLA and ES in teaching hospitals, this might be caused by underdiagnosis of such conditions in non-teaching rural institutions compared to large teaching hospital systems and these were not associated with an increase rate of mortality. There is need for more research to determine the factors impacting the higher costs of atrial fibrillation admissions amongst teaching institutions. Funding Acknowledgement Type of funding sources: None.

Impact of telehealth in the outpatient management of atrial fibrillation during the COVID-19 pandemic

Abstract Background The COVID-19 pandemic accelerated adoption of a telehealth model to replace outpatient visits. We studied quality indicators and clinical outcomes associated with virtual visits in comparison to in-person ambulatory visits for patients with atrial fibrillation (AF) seen by electrophysiology providers. Methods Quality indicators and outcomes for patients with primary diagnosis of AF seen by electrophysiology providers (6 physicians and 4 nurse practitioners) for the 12 week period of March 22–June 13, 2020 were compared with those from the 12 week period of March 24–June 15, 2019. Result We identified 2340 clinic visits for AF (1081 in 2019 and 1259 in 2020). Telehealth was not used in 2019, and was used in 90.5% of the 2020 visits. On multivariate analysis during 120 days following each encounter, there was no difference in hospital admissions between 2019 and 2020 (OR 0.89; 95% CI 0.69–1.14; p=0.3624), and there was trend towards lower emergency department visits in 2020 compared with 2019 (OR 0.77; 95% CI 0.6–1; p=0.0509). There were 36 deaths at 120 days, mortality was similar in 2020 as compared with 2019 (OR 1.5; 95% CI 0.74–3.03; p=0.2601). There was no difference in completed procedures including permanent pacemakers, cardiac resynchronization therapy devices, implantable cardioverter-defibrillators and catheter ablations. There was a significant difference in anticoagulant (OR 0.71; 95% CI 0.52–0.99; p=0.0412) and antiarrhythmic (OR 0.78; 95% CI 0.61–0.99; p=0.0384) dose adjustment or new prescriptions in 2019 compared with 2020. Conclusion Telehealth was associated with similar intermediate-term clinical outcomes when compared to traditional ambulatory encounters. However, adjusting or providing new prescriptions for anticoagulant or anti-arrhythmic medications was more common with in-person than with virtual visits. Funding Acknowledgement Type of funding sources: None.

Reflux esophagitis is associated with higher risks of acute stroke and transient ischemic attacks in patients hospitalized with atrial fibrillation: A nationwide inpatient sample analysis.

Reflux esophagitis (RE) is a subset of gastroesophageal reflux disease (GERD) with endoscopic evidence of esophageal inflammation, which has been linked to an increased incidence of atrial fibrillation (AF). However, data on the effect of RE on patient outcomes is limited. We sought to examine the potential association of RE with outcomes of patients with AF in a nationwide study.The National Inpatient Sample (NIS) database was queried to identify hospitalized adult patients with AF and RE between 2010 and 2014. Primary outcomes included inpatient mortality, length of stay (LOS), and total hospital charges. AF related complications such as acute stroke, transient ischemic attack (TIA) and acute heart failure were assessed as secondary outcomes. Propensity score matching and multivariate regression analysis were used.Six lakh sixty seven thousands five hundred twenty patients were admitted for primary diagnosis of AF out of which 5396 had a secondary diagnosis of RE. In the AF with RE cohort, the average age was 73.6 years, 41.5% were male, and 79.9% were Caucasian. There was a greater prevalence of concomitant dyslipidemia, chronic liver disease and chronic pulmonary disease (P < .01) when compared to the AF without RE cohort. Patients with AF and RE also had higher incidence of acute strokes and TIAs (P < .05), longer LOS (P < .001), and higher hospital charges (P < .05) with no difference in acute heart failure (P = .08), hospital mortality (P = .12), or CHA2DS2-VASc score (P = .67).In hospitalized patients with AF, RE was associated with a higher rate of acute stroke and TIAs, longer LOS, and greater hospital charges.

The Impact of COVID-19 on Admissions and Management of Patients with Atrial Fibrillation Episodes in the Emergency Department.

Background: During the COVID-19 pandemic, the number of admissions to the emergency department (ED) due to a primary diagnosis of atrial fibrillation (AF) has decreased when compared to pre-pandemic times. The principal aim of the study was to assess the frequency of SARS-CoV-2 infections and sinus rhythm restoration among patients who arrived at the ED with AF. Secondary aims included determining whether patients arriving at the ED principally due to AF delayed their presentations and whether the frequency of successful cardioversion for AF was decreased during the pandemic period. Materials and Methods: A retrospective analysis of medical records of patients admitted to two hospital EDs due to AF during July–December 2019 (pre-pandemic period) versus July–December 2020 (pandemic period) was performed. Results: During the study periods, 601 ED visits by 497 patients were made due to the primary diagnosis of AF. The patients were aged 71.2+/−13.5 years and 51.3% were male. The duration of an AF episode before the ED admission was 10 h (4.5–30 h) during the pandemic period vs. 5 h (3–24 h) during the non-pandemic period (p = 0.001). A shorter duration of the AF episode before ED admission was associated with the successful restoration of the sinus rhythm. During the pandemic period, among patients with short-lasting AF who were not treated with Phenazolinum, the restoration of the sinus rhythm was more frequent in the Copernicus Memorial Hospital than in the University Hospital (p = 0.026). A positive SARS-CoV-2 test was found in 5 (1%) patients, while 2 other patients (0.5%) had a prior diagnosis of COVID-19 disease noted in their medical history. Conclusions: 1. The number of AF episodes treated in these two EDs was lower during the pandemic than non-pandemic period. 2. The patients with AF appeared at the ED later after AF onset in the pandemic period. 3. Successful cardioversion of atrial fibrillation was more frequent during the pre-pandemic period in one of the two hospitals. 4. A difference of approaches to the treatment of short-lasting AF episodes between EDs during the pandemic period may exist between these two EDs. 5. The patients with SARS-CoV-2 infection during the second wave of the COVID-19 pandemic constituted a small percentage of the patients admitted to EDs due to an AF episode.

Gender differences, outcomes and trends among nonagenarian with atrial fibrillation: insight from National Inpatient Sample database.

BACKGROUNDNonagenarians (NG), individuals aged ≥ 90 years, constitute an increasing proportion of hospitalizations presenting with atrial fibrillation (AF). However, not much is known about demographics, clinical outcomes, and trends of hospitalizations. Therefore, we analyzed data about hospitalizations and clinical outcomes among NGs with AF over ten years from 2005 to 2014 using a publically available database, the National Inpatient Sample.METHODSAll hospitalizations and major outcomes of subjects ≥ 90 years with a primary diagnosis of AF (ICD-9-CM code 427.31) over a ten-year period were assessed in this study by multivariate logistic regression analysis.RESULTSThere were more females than males (176,268 females, 51,384 males) in this analysis. The number of hospitalizations for AF among NG increased by 50% (17,295 in 2005 to 25,830 in 2014). Males were more likely to undergo cardioversion (6.14% of males vs. 5.06% of females, P < 0.0001). Over this period, in-hospital mortality declined from 3.21% in 2005 to 2.38% in 2014 ( P = 0.0041), with higher in-hospital mortality in males (3.23% in males vs. 2.76% in females, P = 0.0138), mean length of hospitalization decreased from 4.53 days to 4.13 days (P < 0.0001), the prevalence of congestive heart failure fell from 0.48% to 0.23% ( P = 0.0257), and the use of anticoagulation increased from 6.09% to 14.54% (P < 0.0001). In a multivariate analysis, hospital admission on the weekend, Elixhauser comorbidity index, CHA 2DS2VASc score, acute respiratory failure, and the length of hospital stay were associated with a higher risk of in-hospital mortality. CONCLUSIONSFrom 2005 to 2014, AF-related hospitalizations among NGs increased, more so in in females population, mortality trends improved, rates of anticoagulation increased, and cardioversions increased. Despite the decreasing trend of in-hospital mortality since 2005, the relatively high mortality rate in males warrants further studies.

Amiodarone is associated with increased short-term mortality in elderly atrial fibrillation patients with preserved ejection fraction.

Amiodarone is commonly used in atrial fibrillation (AF). Long-term use of amiodarone is associated with significant toxicities especially in elderly patients. However, in the short term after hospitalization of AF, it remains uncertain whether the use of amiodarone will increase mortality. We aim to investigate whether Amiodarone affects short-term mortality in elderly patients after hospitalization for atrial fibrillation. We conducted a single-center retrospective cohort study including patients (Age > = 60 years old) who were hospitalized between 07/01/2004 and 06/30/2019 with primary diagnosis of AF and left ventricular ejection fraction (LVEF) > = 50%. Patients who were prescribed amiodarone during hospitalization but not before hospitalization are classified into Amiodarone group (341 patients). Patients who were not prescribed amiodarone are classified into non-amiodarone group (2171 patients). Propensity score matching was performed with 1:1 nearest-neighbor matching of Amiodarone group and Non-amiodarone group based on baseline variables. Univariate and Multivariate logistic regression were used to calculate the odds ratio of amiodarone use on in-hospital mortality, and multivariate cox regression was adopted to calculate the hazard ratio of amiodarone use on 100-day mortality. Patients' baseline demographic and clinical characteristics were well matched in both groups. Both univariate and multivariate logistic regression showed amiodarone group had higher in-hospital mortality (OR 10.27, p = 0.0268; 16.50, p = 0.0171) than non-amiodarone group and multivariate Cox regression suggested increased 100-day all-cause mortality (HR 2.34, p = 0.022). Amiodarone use in elderly patients with preserved ejection fraction is associated with increased in-hospital and 100-day all-cause mortality after hospitalization for AF.

Guideline-Concordant Antiarrhythmic Drug Use in the Get With The Guidelines-Atrial Fibrillation Registry.

Antiarrhythmic drug (AAD) therapy for atrial fibrillation (AF) can be associated with both proarrhythmic and noncardiovascular toxicities. Practice guidelines recommend tailored AAD therapy for AF based on patient-specific characteristics, such as coronary artery disease and heart failure, to minimize adverse events. However, current prescription patterns for specific AADs and the degree to which these guidelines are followed in practice are unknown. Patients enrolled in the Get With The Guidelines-Atrial Fibrillation registry with a primary diagnosis of AF discharged on an AAD between January 2014 and November 2018 were included. We analyzed rates of prescription of each AAD in several subgroups including those without structural heart disease. We classified AAD use as guideline concordant or nonguideline concordant based on 6 criteria derived from the American Heart Association/American College of Cardiology/Heart Rhythm Society AF guidelines. Guideline concordance for amiodarone was not considered applicable, since its use is not specifically contraindicated in the guidelines for reasons such as structural heart disease or renal function. We analyzed guideline-concordant AAD use by specific patient and hospital characteristics, and regional and temporal trends. Among 21 921 patients from 123 sites, the median age was 69 years, 46% female and 51% had paroxysmal AF. The most commonly prescribed AAD was amiodarone (38%). Sotalol (23.2%) and dofetilide (19.2%) were each more commonly prescribed than either flecainide (9.8%) or propafenone (4.8%). Overall guideline-concordant AAD prescription at discharge was 84%. Guideline-concordant AAD use by drug was as follows: dofetilide 93%, sotalol 66%, flecainide 68%, propafenone 48%, and dronedarone 80%. There was variability in rate of guideline-concordant AAD use by hospital and geographic region. Amiodarone remains the most commonly prescribed AAD for AF followed by sotalol and dofetilide. Rates of guideline-concordant AAD use were high, and there was significant variability by specific drugs, hospitals, and regions, highlighting opportunities for additional quality improvement.

Evaluating the Use of Warfarin Using the HAS-BLED Score and INR on Atrial Fibrillation Patients at Harapan Kita National Heart Center

Patients with atrial fibrillation are associated with a 4-5-fold risk of having a stroke. The most effective treatment for atrial fibrillation is to prevent the formation of blood clots by administering anticoagulant drugs. Warfarin is an anticoagulant drug that has a narrow therapeutic index with side effects of the risk of bleeding; hence it needs supervision in its use. In this study, the HAS-BLED score was used to measure major bleeding risk and as a value representing each risk factor for bleeding. The bleeding risk can be prevented by maintaining a warfarin response in the therapeutic range with an INR (International Normalized Ratio) measurement 2-3. This study was an observational study conducted with retrospective data collection through medical records of patients with a primary diagnosis of atrial fibrillation who received oral warfarin anticoagulant therapy at Harapan Kita National Heart Center in the period of January-December 2017. Using a sample of 40 patients who met the inclusion criteria. According to the data, found that atrial fibrillation patients who received oral warfarin therapy 55% were male patients, while 45% were female patients. Patients with atrial fibrillation who got the most oral warfarin therapy were patients who were over 40 years old with 90% of the total sample, with the highest group in patients aged 50-54 years with 22.5%. The HAS-BLED values arranged from 0-9, the percentage of patients who had HAS-BLED values of 0, 1, 2 respectively at 7.5%, 42.5%, 30%. The HAS-BLED score ≥ 3 showed patients classified as at high risk of bleeding by 20%. The most risk factors based on HAS-BLED score from all study samples were 18 patients with abnormal kidney or 45%. The average INR score in patients at high risk of bleeding showed that 37.5% had an average INR score in the target ratio score of INR 2-3.

Amiodarone use in elderly atrial fibrillation patients with preserved ejection fraction is associated with increased short-term mortality

Abstract Background Amiodarone is commonly used in atrial fibrillation (AF). Long-term use of amiodarone is associated with significant toxicities, especially in elderly patients. However, in the short term after hospitalization of AF, it remains uncertain whether the use of amiodarone will increase mortality. Methods We conducted a retrospective cohort study including patients (Age≥60 years old) who were hospitalized between 07/01/2004 and 06/30/2019 with a primary diagnosis of AF and left ventricular ejection fraction (LVEF) ≥50%. Patients who were prescribed amiodarone during hospitalization but not before are considered as amiodarone group (348 patients). Patients who weren't prescribed amiodarone are considered as non-amiodarone group (2260 patients). Univariate analysis solely analyzed amiodarone use on the all-cause mortality (Kaplan-Meier Curve), and possible confounders were adjusted in the multivariate analysis including age, gender, diabetes mellitus (DM), hypertension (HTN), coronary artery disease (CAD), as well as LVEF, left atrium internal diameter, use of other rate control medications (e.g. beta-blocker). The proportional-hazard assumption was tested by Log-rank test and a 2-sided P value of &amp;lt;0.05 is considered statistically significant. The hazard ratio and 95% confidence interval (CI) were calculated. Results Patients' baseline characteristics were listed in Table 1. Both Univariate and Multivariate analysis showed amiodarone group had higher in-hospital (hazard ratio 2.06; p=0.036) and 100-day mortality (hazard ratio 1.86; p=0.028). Other rate control medication use was also associated with increased mortality but not statistically significant. The results are showed in Figure 1. Conclusion Amiodarone use in elderly patients with preserved ejection fraction is associated with increased short-term all-cause mortality after hospitalization of AF. Figure 1. KM Curve &amp; ForestPlot of Mortality Funding Acknowledgement Type of funding source: None

Implications of presenting to hospital with AF: the REVIEW AF study

Abstract Background There is a growing burden of hospitalizations due to atrial fibrillation (AF). The implications of hospitalisation to the individual with AF has not been well characterized. Purpose To characterise the consequences of presenting to hospital with AF. Methods Individuals presenting to the emergency department (ED) of three hospitals in South Australia from March 2013 to February 2014 with a primary diagnosis of AF were enrolled. Based on coding and individual electronic medical record review all re-presentations over follow up were characterised as: 1) AF related; 2) cardiovascular related (excluding AF); or 3) all other causes. Mortality over follow up was also determined. Results The study cohort comprised of 437 individuals with an AF related index presentation. Mean age was 69±15 years and 49.9% were male. Individuals were followed for a mean of 3.7±0.4 years. There were 2304 unplanned presentations over follow up. The percentage of the study cohort who presented to the ED or were admitted to hospital over follow up is detailed in Figure 1. Compared to individuals who did not have a hospital admission for AF over follow up, those who were readmitted for AF were more likely to be hypertensive (63.2% vs 49.3%, p&amp;lt;0.001); and have a higher CHA2DS2-VASc score (3.2±1.8 vs 2.7±1.9, p=0.002) and HAS-BLED score (2.0±1.0 vs 1.5±1.1, p&amp;lt;0.001). A total of 71 individuals (16.2%) died during the follow-up period (annual mortality rate of 3.78%). Conclusions A hospital presentation with a primary diagnosis of AF identifies individuals at high risk of repeat hospitalisations and death. Urgent studies are needed to improve management of this high-risk cohort. Figure 1. Repeat hospital presentations in AF Funding Acknowledgement Type of funding source: None

Opportunities to reduce the risk of stroke in AF: the REVIEW AF study

Abstract Background Stroke is one of the most devastating complications of atrial fibrillation (AF) and is associated with poor patient outcomes. Recent registry data has demonstrated improved use of stroke prevention therapy with the advent of direct-acting oral anticoagulants, but little data exists in the Australian health care setting. Purpose To examine the use of oral anticoagulant therapy in a cohort of individuals presenting to the emergency department (ED) due to AF. Methods A total of 437 consecutive individuals who presented to the ED with a primary diagnosis of AF to three tertiary hospitals in our city in South Australia between March 2013 and March 2014 were included. Data were collected retrospectively from electronic medical record review. CHA2DS2-VASc and HAS-BLED scores were calculated and any documented contraindications to the use of oral anticoagulation (OAC) taken in to consideration. Results Mean age was 69±15 years and 49.9% were male. A total of 244 (55.8%) individuals had a prior diagnosis of AF at index presentation. 179 (73.4%) of these individuals recorded a CHA2DS2-VASc score of ≥2. A total of 124 of these individuals were appropriately anticoagulated (69.3%) whilst 37 individuals were not treated with OAC and did not have a documented contraindication (20.7%). Anticoagulation status was unknown in 18 individuals due to a lack of documentation (10.0%). A CHA2DS2-VASc score of 0 was recorded in 25 individuals with a prior diagnosis of AF at index presentation with 3 individuals (12%) inappropriately overtreated with OAC. The remaining 193 individuals (44.2%) presented with a first episode of AF. In 129 (66.8%) of these individuals a CHA2DS2-VASc score of ≥2 was recorded and only 10 individuals had a documented contraindication to the use of OAC. In 119 (61.7%) individuals there were no documented contraindications to the use of OAC. In 74 (62.2%) of these presentations OAC was not commenced, whilst in 45 (37.8%) individuals OAC was prescribed. Conclusions Significant opportunity exists to improve the use of stroke prevention therapy in AF. Despite repeated opportunities to commence this therapy within the hospital setting, it remains frequently underutilised in individuals at high risk of stroke. Funding Acknowledgement Type of funding source: None

Utilization and procedural adverse outcomes associated with Watchman device implantation.

The Food and Drug Administration (FDA) approval of the Watchman device [percutaneous left atrial appendage occlusion (LAAO)] has resulted in the widespread use of this procedure in many centres across the USA. We sought to estimate the nationwide utilization and frequency of adverse outcomes associated with Watchman device implantation. The objective of this study was to evaluate the Watchman device implantation peri-procedural complications and comparison of the results with the previous studies. The National Inpatient Sample (NIS) was queried for all hospitalizations with a primary diagnosis of atrial fibrillation or atrial flutter during the year 2016 with percutaneous LAAO during the same admission (ICD-10 code-02L73DK). The frequency of peri-procedural complications, including mortality, procedure-related stroke, major bleeding requiring blood transfusion, and pericardial effusion, was assessed. We compared the complication rates with the published randomized controlled trials and the European Watchman registry. An estimated 5175 LAAO procedures were performed in 2016. The majority of procedures was performed in males (59.1%), age ≥75 years (58.7%), and White (83.1%). The overall complication rate was 1.9%. The in-hospital mortality was 0.29%. Pericardial effusion requiring pericardiocentesis was the most frequent complication (0.68%). Bleeding requiring transfusion was noted in 0.1% of device implants. The rates of post-procedure stroke and systemic embolism were 0% and 0.29%, respectively. Percutaneous LAAO with the Watchman device in the USA is associated with low in-hospital complications and a similar safety profile to a recently published EWOLUTION cohort. The complication rates were lower than those reported in the major randomized clinical trials (RCTs). We report the frequency of peri-procedural complications of the LAAO using the Watchman device from the NIS database. We also compare the frequency of peri-procedural complications with the previously published RCTs and EWOLUTION cohort. Our findings are in concordance with findings from EWOLUTION cohort and compare favourably with RCTs.

Practice Gap in Atrial Fibrillation Oral Anticoagulation Prescribing at Emergency Department Home Discharge

IntroductionCurrent U.S. cardiology guidelines recommend oral anticoagulation (OAC) to reduce stroke risk in selected patients with atrial fibrillation (AF), but no formal AF OAC recommendations exist to guide emergency medicine clinicians in the acute care setting. We sought to characterize emergency department (ED) OAC prescribing practices after an ED AF diagnosis.MethodsThis retrospective study included index visits for OAC-naive patients ≥18 years old who were discharged home from the ED at an urban, academic, tertiary hospital with a primary diagnosis of AF from 2012–2014. Five hypothesis-blinded, chart reviewers abstracted data from patient problem lists and medical history in the electronic health record to assess stroke (CHA2DS2-VASc) and bleeding risk (HAS-BLED). The primary outcome was the provision of an OAC prescription at discharge in OAC-naive patients with high stroke risk. Descriptive statistics and multivariable logistic regression assessed associations between OAC prescription and patient characteristics.ResultsWe included 138 patient visits in our analysis, of whom 39.9% (n = 55) were low stroke risk (CHA2DS2-VASc = 0 in males and 1 in females), 15.9% (n = 22) were intermediate risk (CHA2DS2-VASc = 1 in males), and 44.2% (n = 61) were high risk (CHA2DS2-VASc ≥ 2). Of patients with high stroke risk and low-to-intermediate bleeding risk (n = 57), 80.7% were not prescribed an OAC at discharge. Cardiology consultation and female gender, but not stroke risk (CHA2DS2-VASc score), were predictors of an ED provider prescribing an OAC to an OAC-naive AF patient at ED discharge.ConclusionThe majority of OAC-eligible patients were discharged home without an OAC prescription. In OAC-naive patients discharged home from the ED, cardiology consultation and female gender were associated with OAC prescription. Our findings suggest that access to expert opinion may improve provider comfort with OAC prescribing and highlight the need for improved guidelines specific to ED-management of AF.

Abstract 217: Are Discharge Rate Control Medications Adequate for Future Atrial Fibrillation Needs?

Background: Rate control medications (RCM) for atrial fibrillation (AF) usually prescribed are diltiazem (DTZ) and beta blockers. Patients entering the Emergency Department (ED) with AF often convert to a normal sinus rhythm (NSR) by means of spontaneous conversion to normal sinus rhythm (SCNSR), electrical cardioversion, or medications. However, recurrent AF often leads to repeat ED visits and frequent hospitalizations within one year. Goals: To evaluate admission and discharge metoprolol (MTP) and DTZ doses for patients presenting to the ED with rapid AF. Methods: Retrospective, single center chart review of MTP and DTZ doses on admission and discharge for patients admitted with a primary diagnosis of AF. Patients who received new or an increase of other RCMs, or antiarrhythmic medications with RCM properties were excluded. Results: Of 402 patients, 310 (77%) had a heart rate ≥110 bpm on admission. Of those with a rapid rate, 235 (76%) converted to NSR after admission predominantly due to SCNSR. The mean daily dose of MTP was 61mg on admission and 65mg at discharge. The mean DTZ dose on admission was 188mg and 157mg at discharge. Discussion: The discharge doses of 65mg of MTP and 157mg of DTZ were well below the recommended doses of RCMs for AF. The RATAF trial demonstrated adequate rate and symptom control with MTP 100mg/day and DTZ up to 360mg/day. The current study demonstrated significant under dosing of RCMs to manage future rapid ventricular rate. It is possible patients with rapid ventricular rates who convert to NSR, which by itself, results in rate control, would not have attention by the provider focused on the rapid admission rate. Most patients who convert to NSR do not have the substrate leading to AF corrected. Thus, it is not surprising recurrence of AF, regardless of the method of cardioversion, occurs in approximately 70% of patients within one year. It is likely when AF recurs it will have the same rapid rate unless RCMs are increased before discharge from the first initial admission dose. It is possible at discharge an order set may lead to a more logical assessment of targeted RCMs. Lack of long term follow-up to address outcome of apparent under dosing of RCM is a limitation. Conclusion: This single center study found no significant increases in MTP and DTZ dosing at the time of discharge for patients with rapid AF who reverted to NSR after admission. It is possible that modification of RCMs before hospital discharge may decrease future ED admission for symptomatic AF.

Risk of Ischemic Stroke and Major Bleeding in Patients with Atrial Fibrillation and Cancer

Background: Atrial fibrillation (AF) is an important risk factor for ischemic stroke. Cancer may increase the risk both of ischemic stroke and of bleeding. Less is known about risk of ischemic stroke and bleeding among cancer patients with AF, complicating the prevention of ischemic stroke in these patients. Methods: Register based cohort study comprising all Swedish patients hospitalized with a primary diagnosis of AF from July 1, 2005 until December 31, 2014. Patients with cancer diagnosis were compared to the rest of the cohort. We repeated the analysis focusing on recent cancer diagnosis and on cancer types prone to thromboembolism. Associations between predictor and outcome variables were analyzed with Cox regression. Results: The cohort consisted of 294,989 AF patients including 71,882 with prior cancer diagnosis. After adjustments, neither cancer diagnosis overall, recent cancer diagnosis, or any subgroup of cancer were associated with increased risk of ischemic stroke. Several cancer forms were however associated with risk of major bleedings, including risk of intracranial hemorrhage for patients with prostate cancer and risk of gastrointestinal bleeds for patients with colorectal and pancreatic cancer, adjusted hazard ratios with 95% confidence intervals 1.31 (1.06-1.62), 1.74 (1.53-1.97), and 2.86 (1.80-4.55) respectively. Conclusion: Cancer diagnosis was not associated with increased risk of ischemic stroke but several cancer forms were associated with risk of major bleedings in this large, Swedish cohort of AF patients. The results may have implications for prevention of ischemic stroke in these patients.

Prescribing of oral anticoagulants in the emergency department and subsequent long-term use by older adults with atrial fibrillation.

Patients with atrial fibrillation frequently seek emergency care. Rates of guideline-concordant oral anticoagulant therapy for stroke prevention are suboptimal in the community. We assessed the association between prescribing of oral anticoagulants in the emergency department (relative to referral to a longitudinal care provider for treatment initiation) and long-term use of oral anticoagulants. This retrospective cohort study performed at 15 hospitals in Ontario, Canada, involved patients aged 65 years or older who visited the emergency department between 2009 and 2014, who had a primary diagnosis of atrial fibrillation, were discharged home, and were eligible for and willing to take stroke-prevention therapy. We used inverse probability-of-treatment weighting based on the propensity score to compare patients who were and were not given a prescription for an oral anticoagulant. The primary outcome was a prescription fill for an oral anticoagulant 6 months later. Secondary outcomes included a prescription fill at 1 year, all-cause mortality, and strokes or bleeding events leading to hospital admission. Of 2132 eligible patients, 402 (18.9%) were given a prescription for an oral anticoagulant in the emergency department. After weighting, 67.8% of these patients had filled a prescription for an oral anticoagulant at 6 months versus 37.2% of those who did not receive a prescription in the emergency department (absolute risk increase [ARI] 30.6%, number needed to treat [NNT] 3). At 1 year, the ARI was 23.2% and the NNT was 4. Rates of death, stroke and bleeding events did not differ significantly. In patients with atrial fibrillation who were eligible for stroke prevention, prescribing an oral anticoagulant in the emergency department was associated with substantially higher long-term use of oral anticoagulants compared with deferring to the longitudinal care provider to initiate this therapy. Physicians working in the emergency department should consider initiating oral anticoagulation in eligible patients who are being discharged to home.

Impact of cardiology follow-up care on treatment and outcomes of patients with new atrial fibrillation discharged from the emergency department.

The first presentation of atrial fibrillation (AF) is often to an emergency department (ED). We evaluated the association of subsequent specialist care with morbidity and mortality. Retrospective cohort study of all adults in Alberta, Canada, with a new primary diagnosis of AF treated and released during an index ED visit between 2009 and 2015. Types of physician follow-up within 3 months of ED visit was analysed using Cox proportional hazards models with time-varying covariates. Outcomes were evaluated at 1 year. Of 7986 patients, 476 (6.0%) had no physician follow-up within 3 months, whereas 2730 (34.2%) attended a non-specialist only, 1277 (16.0%) an internal medicine specialist, and 3503 (43.9%) cardiology. An increasing gradient of cardiac investigations occurred across these groups. Cardiology compared with non-cardiologist care was associated with approximately two-fold greater electrophysiology interventions and revascularization, and increased use of beta-blockers (48.9% vs. 43.0%, P < 0.0001), statins (31.4% vs. 26.7%, P < 0.0001), and oral anticoagulation in patients with CHADS2 scores ≥1 (53.7% vs. 43.6%, P < 0.0001). In the subsequent year, cardiology care was associated with fewer deaths [adjusted hazard ratio (aHR) 0.72, 95% confidence interval (CI) 0.55-0.93], strokes (aHR 0.60, 95% CI 0.37-0.96), or major bleeds (aHR 0.69, 95% CI 0.53-0.89). No differences in the risk of hospitalization or ED visits were associated with cardiology care. Cardiology care after an ED visit for symptomatic new-onset AF is associated with better prognosis. The benefit may be mediated through more intensive investigation, identification, and treatment of cardiovascular risk factors and disease.