P059: “Rate and See” – a pilot evaluation of a short duration atrial fibrillation pathway linking the emergency department to specialty care

Abstract

Introduction: Rapid atrial fibrillation (AF) and flutter remains a common cause of emergency department (ED) visits. Canadian guidelines recommend a rhythm control strategy for patients presenting to ED within 48 hours of arrhythmia onset or who are anticoagulated. However, up to 70% of patients spontaneously convert within 24 hours, mitigating the need for urgent cardioversion. Moreover, education, risk stratification, appropriate anticoagulation, and follow-up may be challenging in the ED setting. Therefore, direct and rapid linkage to an AF clinic was proposed to address these gaps in care. Methods: A pilot evaluation of a “Short Duration AF Pathway” was performed at Kelowna General Hospital, B.C., from June 2014 to Feb 2015. This care pathway–consisting of a treatment algorithm, ED order set, and referral process–was applied to patients with AF≤48 hours or those who were anticoagulated. Patients received initial rate control medication in the ED and were referred for reassessment in a collaborative cardiologist/nurse practitioner AF clinic and seen within 24 hours. Data was collected prospectively; descriptive statistics are presented. Results: Twenty patients were enrolled during the pilot period. Mean age was 69 (SD=10) years, 6/20 (30%) female, mean CHADS65 score 1.35 (SD=1.1), with 15/20 (75%) CHADS65 ≥ 1. On presentation, 4/20 (20%) were taking anticoagulants and 12/20 (60%) had an AF history. All 20 patients were assessed in the AF clinic within 24 hours of referral. Upon assessment in the AF clinic, 10/20 (50%) had spontaneously converted to sinus rhythm and 5/20 (25%) were electrically cardioverted at the first AF clinic visit. The remaining 5/20 (25%) of patients were reclassified as AF of uncertain duration; one was admitted to hospital, the other four had delayed electrical cardioversion. All patients received education related to AF. No adverse events or readmissions to the ED were reported and 100% of patients with CHADS 65≥1 had received appropriate anticoagulation. Conclusion: A “Short Duration AF Pathway” is a viable alternate approach to immediate cardioversion within the ED. Potential advantages include avoiding unnecessary cardioversion, providing patient education, accessing timely specialty care, and initiating anticoagulation where appropriate.