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Health See other Health Articles Title: ED Treatment of AF May Not Help Patients With Acute Underlying Medical Illness NEW YORK (Reuters Health) - Emergency department treatment of atrial fibrillation (AF) or flutter in patients with acute underlying medical illness is associated with a six-fold jump in adverse events, according to a new study. Rate and rhythm strategies appear safe for most of the half a million patients annually who visit emergency departments for AF or flutter, but patients with acute underlying medical conditions have been excluded from most studies supporting such use, researchers say. Dr. Frank X. Scheuermeyer from St. Paul's Hospital and the University of British Columbia in Vancouver, Canada, and colleagues investigated the safety and success of rate and rhythm control in a retrospective study of more than 400 such patients. Of the 350 patients with atrial fibrillation and 66 with atrial flutter, 105 received rate control, 15 had chemical rhythm control attempts, 15 had electrical rhythm control attempts, and 281 received no arrhythmia-specific therapy. Most patients had an unclear time of onset of their arrhythmia, and most presented with dyspnea or weakness, rather than palpitations or chest pain, the researchers report in Annals of Emergency Medicine, online November 6. Fewer than one in 10 had pulse rates above 150 beats/min, and less than 5% had systolic blood pressures below 90 mm Hg. At least one adverse event emerged in 55 of 135 (40.7%) patients who received rate or rhythm control, compared with only 20 of 281 (7.1%) patients who did not receive rate or rhythm control. Moreover, patients who received rate or rhythm control were 11.7 times more likely to have a major adverse event. After adjustment for propensity scores, patients who received rate or rhythm control were 8.3 times more likely to have an adverse event. And the attempted treatment was not very successful. Only 20 of 105 (19%) patients who received rate control achieved pulse reductions of at least 20 beats/min within four hours, and only four of 30 (13.3%) patients who received attempted rhythm control converted to normal sinus rhythm. About twice as many patients who received no specific therapy (125/281, 44.5%) had pulse rate reductions of at least 20 beats/min, but none of these patients spontaneously converted to normal sinus rhythm. "We can surmise from this study, and common sense, that treating the acute underlying illness first may make more sense than aggressively treating the atrial fibrillation or flutter," said Dr. Darryl Elmouchi from Frederik Meijer Heart and Vascular Institute in Grand Rapids, Michigan, who has studied ED treatment of AF. "As healthcare providers, just because we can treat something, doesn't mean we should," Dr. Elmouchi, who was not involved in the new work, told Reuters Health by email. "As atrial fibrillation, in particular, is becoming more common, we will see more and more patients present with acute illness not necessarily caused by their rhythm disturbance. We must be vigilant in using common sense when evaluating and treating these patients." Dr. Tyler W. Barrett from Vanderbilt University Medical Center, Nashville, Tennessee has also studied the risk of adverse events in patients presenting to the emergency department with atrial fibrillation. "This study suggests that emergency physicians need to consider whether there is some underlying cause that precipitated the acute exacerbation of atrial fibrillation or atrial flutter especially in the older, more complex, AF patient population," he told Reuters Health by email. "As Dr. Scheuermeyer points out, there is essentially no discussion in the international, US, or European guidelines on the acute management of AF," Dr. Barrett said. "As the worldwide prevalence of AF continues to increase, the number of ED visits for AF will only continue to increase. An interdisciplinary guideline on managing acute AF in the ED that provides recommendations not only for best practices in treatment (rate vs. rhythm control) but also disposition (who should be admitted, who should be managed as outpatients) would greatly benefit both the patients with AF and the emergency medicine physicians who treat these individuals daily." Dr. Scheuermeyer did not respond to a request for comments. SOURCE: bit.ly/1teNEQG Ann Emerg Med 2014. Editors' Recommendations Heart Rhythm Society's Choosing Wisely List Disappoints 2014 AF Treatment Guidelines: 10 Things to Like and Only One to Dislike Poster Comment: the worldwide prevalence of AF continues to increase But no one seems to know why. Post Comment Private Reply Ignore Thread
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