National Survey of Patients With AF in the Acute Medical Unit
National Survey of Patients With AF in the Acute Medical Unit
Of the 220 AMUs initially canvassed, 31 eventually provided patient data, representing a population base of more than seven and a half million adult UK residents (figure 1). The electronic questionnaire was completed for 149 patients (Table 1). The symptom profile and AF status of the patients is displayed in Table 2.
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Figure 1.
Atrial fibrillation (AF) survey recruitment flow chart
Sepsis was the principal associated diagnosis present in almost a third, followed by heart failure and cerebrovascular events (figure 2). The hierarchy of associated diagnoses was different for the elderly, where cerebrovascular events ranked highest, together with sepsis and heart failure accounting for 70% of presentations (figure 3).
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Figure 2.
Diagnosis reported in association with AF
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Figure 3.
Diagnosis reported in association with AF in patients aged 80–89 years
In line with NICE guidelines, all patients received a resting 12-lead electrocardiogram (ECG). Abnormal QRS morphology, predominantly left bundle branch block, was noted in 17%, and repolarisation changes were seen in 13% (Table 3).
Less than a quarter of the study population (23%) had any form of stroke risk assessment (NICE, CHADS2, CHA2DS2-Vasc) (Appendix 2). Retrospective CHA2DS2-Vasc scores for those who were not risk stratified averaged 3.5, and the mean age of this subgroup was 77 years. Of note, 73 (80%) patients with a significant risk for thromboembolic stroke (retrospective CHA2DS2-Vasc score >2) were not prescribed anticoagulation therapy at time of discharge. The risk of stroke needs to be balanced with the risk of major haemorrhage. Despite this, only 36% (n=54) of patients with a CHA2DS2-Vasc score >2, had a HAS-BLED score of ≥3 (8.7 major bleeds per 100 patient-years). In addition, 24% (n=15) of patients at risk of major haemorrhage (HAS-BLED score of ≥3) were discharged on anticoagulation therapy. Four of this group were concomitantly discharged on antiplatelet therapy.
Rate control was the principal form of initial management, but one in five patients received digoxin alone (Table 4).
At the time of data collection, information was available for 99 discharged patients (Table 5). One in five was offered inpatient or outpatient cardiology review and most were prescribed rate-limiting medication. Half were discharged on aspirin or clopidogrel, and a quarter on warfarin, with the remainder receiving neither an antiplatelet nor an antithrombotic agent.
In total, 49 (33%) of patients presented out of normal working hours (defined as from 6.30 p.m. to 8.00 a.m. on weekdays, the whole of weekends, bank holidays and public holidays). Documentation of stroke risk was performed less frequently in patients who presented with AF out of hours, though this was not statistically significant (18.4% vs. 27.2%; Fishers exact p=0.29). Patients who presented with AF out of hours tended not to be discharged within 24 hours (28.6% of patients presenting out of hours vs. 45.7% of patients during normal working hours; Fishers exact p=0.06).
Results
Of the 220 AMUs initially canvassed, 31 eventually provided patient data, representing a population base of more than seven and a half million adult UK residents (figure 1). The electronic questionnaire was completed for 149 patients (Table 1). The symptom profile and AF status of the patients is displayed in Table 2.
(Enlarge Image)
Figure 1.
Atrial fibrillation (AF) survey recruitment flow chart
Associated Diagnoses
Sepsis was the principal associated diagnosis present in almost a third, followed by heart failure and cerebrovascular events (figure 2). The hierarchy of associated diagnoses was different for the elderly, where cerebrovascular events ranked highest, together with sepsis and heart failure accounting for 70% of presentations (figure 3).
(Enlarge Image)
Figure 2.
Diagnosis reported in association with AF
(Enlarge Image)
Figure 3.
Diagnosis reported in association with AF in patients aged 80–89 years
Cardiac Investigations
In line with NICE guidelines, all patients received a resting 12-lead electrocardiogram (ECG). Abnormal QRS morphology, predominantly left bundle branch block, was noted in 17%, and repolarisation changes were seen in 13% (Table 3).
Stroke Risk Assessment
Less than a quarter of the study population (23%) had any form of stroke risk assessment (NICE, CHADS2, CHA2DS2-Vasc) (Appendix 2). Retrospective CHA2DS2-Vasc scores for those who were not risk stratified averaged 3.5, and the mean age of this subgroup was 77 years. Of note, 73 (80%) patients with a significant risk for thromboembolic stroke (retrospective CHA2DS2-Vasc score >2) were not prescribed anticoagulation therapy at time of discharge. The risk of stroke needs to be balanced with the risk of major haemorrhage. Despite this, only 36% (n=54) of patients with a CHA2DS2-Vasc score >2, had a HAS-BLED score of ≥3 (8.7 major bleeds per 100 patient-years). In addition, 24% (n=15) of patients at risk of major haemorrhage (HAS-BLED score of ≥3) were discharged on anticoagulation therapy. Four of this group were concomitantly discharged on antiplatelet therapy.
Initial AF Treatment Strategies
Rate control was the principal form of initial management, but one in five patients received digoxin alone (Table 4).
Discharge Planning, Medication and Follow-up
At the time of data collection, information was available for 99 discharged patients (Table 5). One in five was offered inpatient or outpatient cardiology review and most were prescribed rate-limiting medication. Half were discharged on aspirin or clopidogrel, and a quarter on warfarin, with the remainder receiving neither an antiplatelet nor an antithrombotic agent.
Out of Hours
In total, 49 (33%) of patients presented out of normal working hours (defined as from 6.30 p.m. to 8.00 a.m. on weekdays, the whole of weekends, bank holidays and public holidays). Documentation of stroke risk was performed less frequently in patients who presented with AF out of hours, though this was not statistically significant (18.4% vs. 27.2%; Fishers exact p=0.29). Patients who presented with AF out of hours tended not to be discharged within 24 hours (28.6% of patients presenting out of hours vs. 45.7% of patients during normal working hours; Fishers exact p=0.06).
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