FormalPara Clinician’s capsule

What is known about this topic?

The CAEP 2021 Best Practice Checklist provides recommendations for management of acute atrial fibrillation / flutter in the ED.

What did this study ask?

Are ED physicians compliant with the CAEP 2021 Checklist recommendations in acute atrial fibrillation / flutter and are there any safety concerns?

What did this study find?

This study found good compliance to the CAEP recommendations and elements where patient care can be improved in AF/AFL management.

Why does this study matter to clinicians?

Patient care can be optimized by heart rate targeting at disposition, avoidance of calcium channel and beta blockers in systolic dysfunction and cardioversion for unstable patients.

Introduction

Atrial fibrillation and flutter (AF/AFL) are common emergency department (ED) presentations with a documented increase in hospitalizations in the last 2 decades [1]. However, studies suggest that most patients with recent onset AF/AFL may be discharged home directly from the ED after adequate rate and rhythm control [2, 3]. Historically, there was significant variation to physician management of AF/AFL in the ED [4]. The 2021 CAEP Acute Atrial Fibrillation/Flutter Best Practices Checklist was adapted from the Canadian Cardiovascular Society guidelines and offers clear recommendations for safe management of patients presenting with acute AF/AFL [5, 6]. The CAEP Checklist provides guidance on risk stratification, ED management, stroke prevention, disposition, and follow-up [5].

Given the prevalence of these tachyarrhythmias, appropriate management in the ED is integral for patient care and may mitigate rises in hospitalizations [1, 2]. Notably, practice variation is inherent in the ED and has been well documented in the management of AF/AFL [7]. The CAEP Checklist can, therefore, bridge the gap by providing unifying recommendations for ED management of AF/AFL. There are no studies which assess the 2021 CAEP Checklist in clinical practice.

The purpose of this study was to evaluate physician compliance to the 2021 CAEP Checklist with regards to risk assessment and ED management. In particular, we wished to assess safety concerns and adverse events in the management of adult patients presenting to the ED with symptomatic AF/AFL. Secondary outcomes included patient disposition, return to ED for management, and adverse events 30 days post-discharge. A complementary paper evaluates alignment with the second two parts of the checklist: stroke prevention and disposition [8].

Methods

Study design and time period

This health records review compiled all ED visits from January 1, 2022 to August 31, 2022 for patients presenting with acute AF/AFL. This study protocol was approved by our institutional research ethics board.

Study setting

This study was conducted at The Ottawa Hospital (TOH) Civic and General campus EDs, which see 180,000 patients annually. The 2 EDs are staffed by 95 attending physicians, certified in emergency medicine, along with 55 EM residents and fellows.

Population

All adult patients (≥ 18 years of age) presenting to TOH EDs with tachyarrhythmias deemed to have the diagnosis of AF/AFL as a result of primary or secondary causes were included in this study. Patients were excluded if their tachyarrhythmia was not the reason for their presentation or their heart rate was less than 100 bpm.

Data collection procedures

All ED patient visits were obtained from the EPIC health records system based on inclusion criteria to capture primary and secondary causes of AF/AFL. All ECGs were compiled if the diagnosis was “atrial fibrillation” or “atrial flutter” in the machine-generated diagnosis or following staff cardiologist review. These charts were independently reviewed and entered into an encrypted database.

Outcome measures

Safety criteria were identified from the CAEP 2021 recommendations based on consensus from a group of senior ED physicians. These criteria were then categorized into moderate or severe safety concerns. Severe safety criteria included: no electrical cardioversion if the patient was unstable; cardioversion of secondary AF/AFL; calcium channel or beta blocker use in systolic dysfunction; and attempted cardioversion if deemed unsafe based on Checklist criteria. Moderate safety concerns included: cardioversion in permanent AF/AFL; failure to attain a target heart rate by discharge; or inadequate staffing for cardioversion procedures.

Additional outcome measures collected include adverse events during ED management of the arrhythmia including hypotension (systolic blood pressure < 90), bradycardia (heart rate < 60 bpm), hypoxia (SpO2 < 90%), pulmonary edema, cardiogenic shock or cardiac arrest. Finally, we assessed patient disposition, return to ED for management, and adverse events 30 days post-discharge.

Data analysis and sample size

We chose a pragmatic sample size of 300 patients as this was thought to be large enough to be representative of care for patients in the ED and to identify safety concerns. Any discrepancies in safety assessment criteria for patient management on initial screening were reviewed by all members of the study team and resolved by consensus. Data were analyzed through descriptive statistics as appropriate for the data.

Results

Visits from 2,244 patient charts were reviewed and 429 patients met all inclusion criteria (see online supplement). Table 1 outlines the demographics and outcome measures for the included patients. The mean age was 67.7 years with 57.1% being male. Primary and secondary arrhythmias were identified in 86.9% and 13.1% of cases, respectively.

Table 1 Demographics and outcome measures for 429 patients presenting to the ED for management of acute AF/AFL
Full size table

Adverse events occurred in 41 (9.5%) cases. Specifically, there were adverse events in 13.4% of patients who received electrical cardioversion, 6.9% in those who received pharmacological cardioversion, and 12.5% in those who received rate control (see Supplemental Table 1). Bradycardia occurred more often in electrical cardioversion (5.8%) when compared to pharmacologic cardioversion (1.0%) and rate control (1.1%). The incidence of hypotension was greater in pharmacological cardioversion (5.9%) and rate control (5.6%) when compared to electrical cardioversion (1.8%). Other documented adverse events following rate control included pulmonary edema (2.3%), cardiogenic shock (1.1%), and cardiac arrest (1.1%). Notably, the cardiac arrest occurred following beta blocker administration which was deemed appropriate based on CAEP recommendations. Overall, 83.4% of patients were discharged home, 15.9% were admitted to hospital, and 0.7% were deceased. The 30-day return-to-ED rate was 16.5% secondary to AF/AFL. Adverse events occurred in 2.3% of cases within 30 days of ED discharge (see online supplement).

Overall, there were 34 (7.9%) cases with management safety concerns; conversely, 92.1% had no concerns. Moderate safety concerns were identified in 4.9% of cases including failure to achieve a target heart rate at time of discharge (3.9%); inadequate staffing present for cardioversion (0.7%); and attempted cardioversion of permanent AF/AFL (0.2%). Severe safety concerns were identified in 3.0% of cases including failure to electrically cardiovert a clinically unstable patient (1.2%); the use of calcium channel or beta blocker in systolic dysfunction (0.9%); cardioversion in secondary AF/AFL (0.5%); and attempted cardioversion when deemed unsafe based on Checklist recommendations (0.5%).

Discussion

Interpretation of findings

This study highlights that most patients with AF/AFL are effectively managed in the ED with safe disposition home. An aging population and rising incidence of AF/AFL in ED patients with recurrent ED visits highlights the need for standardization of care which the CAEP recommendations provide [1]. We demonstrate that there is generally good physician compliance to the CAEP recommendations. We further emphasize where patient care can be optimized including: attaining a goal heart rate in rate control; appropriate use of AV node blockade agents; and prompt electrical cardioversion when indicated. The adverse events occurring during ED management with rate and rhythm control were generally transient with resolution prior to discharge. Finally, the incidence of adverse events occurring within 30 days of ED management was low with unclear relation to safety of the recommendations.

Comparison to previous studies

This study is the first to evaluate compliance to the 2021 CAEP Checklist for management of AF/AFL. There has been documentation of practice variation for ED management of acute AF/AFL preceding the 2021 CAEP recommendations [7]. The CAEP Checklist provides unifying recommendations which facilitates standardization of care in the ED, thereby optimizing patient care. Furthermore, there is evidence that treatment protocols for AF/AFL can reduce hospital admissions, thereby reducing overall cost to the health care system [9, 10].

Prior assessments of adverse events demonstrated that hypoxia during electrical cardioversion is likely attributed to sedation medications while all other adverse events were transient during ED management [10]. Our study highlights similar findings whereby hypotension, bradycardia, and hypoxia resolved in the ED with high rates of patients being discharged home. A complementary paper from our institution evaluated alignment with recommendations for stroke prevention and disposition, however, did not assess rate and rhythm control [8].

Strengths and limitations

A strength of this study is that it consists of a robust sample size performed at two large tertiary EDs. This facilitates the assessment of a large number of ED physicians which captures potential practice variation. A secondary strength is that this is the first study to compare the CAEP Checklist for acute AF/AFL management in the ED to current clinical practice.

A limitation of this study is that while most physicians practiced in accordance with the CAEP Checklist recommendations, given the study design, it is unclear if clinicians were referring to the Checklist or simply following their own practice. A second limitation is that this study does not account for shared decision-making that physicians have with patients during ED intervention. This includes patient preference for management options whereby patients would elect for pharmacological over electrical cardioversion when the latter would be the mainstay of treatment. We did not involve a non-academic hospital in our study and physician behavior may have been different. Further, we may have missed return-to-ED visits to other hospitals.

Clinical implications

Our study highlights a few areas where patient care can be optimized. This includes targeting a heart rate < 110 bpm with ambulation and < 100 bpm when at rest. In addition, the use of bedside POCUS may assist in evaluating cardiac systolic dysfunction and mitigate adverse events associated with use of calcium channel or beta blockers in these situations. Furthermore, rapid identification of unstable patients for prompt electrical cardioversion is essential to prevent clinical deterioration. Finally, in select cases, alternative management was performed following documentation of patient discussions weighing the risks/benefits of intervention. This highlights the patient-centered care which is provided with physician guidance.

We encourage ED physicians to refer to the CAEP Checklist (open access: https://link.springer.com/article/https://doi.org/10.1007/s43678-021-00167-y) or the free smartphone application (CAEP Atrial Fibrillation Guide on iOS and Android) [5].

Research implications

Currently, there are no studies that assess the 2021 CAEP Checklist in AF/AFL management. Formal implementation studies could facilitate the identification of overall safety of the CAEP recommendations when used in clinical practice. We encourage other hospitals to conduct similar quality assurance reviews to evaluate the safety of local practice and opportunities for improvement.

Conclusion

We found that most ED patients were treated appropriately in accordance with the CAEP Checklist with a low number of safety concerns. Opportunities for improvement include attaining recommended targets during rate control, avoidance of calcium channel and beta blockers in patients with systolic dysfunction, and early consideration of cardioversion for clinically unstable patients.