New-Onset Atrial Fibrillation Among Patients With Infection in the Emergency Department: A Multicenter Cohort Study of 1-Year Stroke Risk.

BACKGROUND: Patients with new-onset atrial fibrillation in relation to infection are frequent in emergency departments (EDs) and may require antithrombotic therapy because of the increased risk of stroke. Our objective was to describe the 1-year risk of stroke in patients in the ED with infection, new-onset atrial fibrillation, and no antithrombotic therapy. METHODS: This was a population-based cohort study at 4 EDs in Denmark and Sweden. Atrial fibrillation was identified by electrocardiogram (ECG) upon arrival at the ED, and infection was identified by discharge diagnosis. Patient history was followed for 12 months or until initiation of oral anticoagulant therapy, ischemic stroke, or death. Primary outcome was stroke within 12 months compared to patients with infection and no atrial fibrillation. RESULTS: In the analysis, 15,505 patients were included; 48.7% were male and the median age was 71 (IQR, 56-83). Among the included patients, 2107 (13.6%) had atrial fibrillation of any kind and 822 (39.0%) of these had new-onset atrial fibrillation with a median CHA2DS2-VASc score of 3 (IQR 2-4). New-onset atrial fibrillation during infection showed an absolute postdischarge 1-year risk of stroke of 2.7% (95% CI 1.6-4.2), corresponding to a crude hazard ratio (HR) of 1.4 (95% CI 0.9-2.3), a sex and age adjusted HR of 1.0 (95% CI 0.6-1.6), and a CHA2DS2-VASc adjusted HR of 1.1 (95% CI, 0.7-1.8) compared to patients with infection but no atrial fibrillation. CONCLUSIONS: Patients in the ED with infection and new-onset atrial fibrillation without current oral anticoagulant therapy had a 2.7% absolute 1-year risk of stroke. Stroke events were mainly related to sex and age and risk factors identified by the CHA2DS2-VASc score.

Etiology of Shock in the Emergency Department: A 12-Year Population-Based Cohort Study.

INTRODUCTION: The knowledge of the etiology and associated mortality of undifferentiated shock in the emergency department (ED) is limited. We aimed to describe the etiology-based proportions and incidence rates (IR) of shock, as well as the associated mortality in the ED. METHODS: Population-based cohort study at a University Hospital ED in Denmark from January 1, 2000, to December 31, 2011. Patients aged ≥18 years living in the ED-catchment area (N = 225,000) with a first-time ED presentation with shock (n = 1,553) defined as hypotension (systolic blood pressure ≤100 mm Hg) and ≥1 organ failures were included. Discharge diagnoses defined the etiology and were grouped as follows: distributive septic shock (SS), distributive non-septic shock (NS), cardiogenic shock (CS), hypovolemic shock (HS), obstructive shock (OS), and other conditions (OC). Outcomes were etiology-based characteristics, annual IR per 100,000 person-years at risk (95% confidence intervals [CIs]), mortality at 0 to 7-, and 0 to 90 days (95% CIs) and hazard rates (HR) at 0 to 7, 8 to 90 days (95% CIs). Poisson and Cox regression models were used for analyses. RESULTS: Among 1,553 shock patients: 423 (27.2%) had SS, 363 (23.4%) NS, 217 (14.0%) CS, 479 (30.8%) HS, 14 (0.9%) OS, and 57 (3.7%) OC. The corresponding IRs were 16.2/100,000 (95% CI: 14.8-17.9), 13.9/100,000 (95% CI: 12.6-15.4), 8.3/100,000 (95% CI: 7.3-9.5), 18.4/100,000 (95% CI: 16.8-20.1), 0.5/100,000 (95% CI: 0.3-0.9), and 2.2/100,000 (95% CI: 1.7-2.8). SS IR increased from 8.4 to 28.5/100,000 during the period 2000 to 2011. Accordingly, the 7-, and 90-day mortalities of SS, NS, CS, and HS were 30.3% (95% CI: 25.9-34.7) and 56.2% (95% CI: 50.7-61.5), 12.7% (95% CI: 9.2-16.1) and 22.6% (95% CI: 18.1-27.7), 34.6% (95% CI: 28.2-40.9) and 52.3% (95% CI: 44.6-59.8), 19.2% (95% CI: 15.7-22.7), and 36.8% (95% CI: 33.3-43.3). SS (HR = 1.46 [95% CI: 1.03-2.07]), and CS (HR = 2.15 [95% CI: 1.47-3.13]) were independent predictors of death within 0 to 7 days, whereas SS was a predictor within 8 to 90 days (HR = 1.66 [95% CI: 1.14-2.42]). CONCLUSION: HS and SS are frequent etiological characteristics followed by NS and CS, whereas OS is a rare condition. We confirm the increasing trend of SS, as previously reported. Seven-day mortality ranged from 12.7% to 34.6%, while 90-day mortality ranged from 22.6% to 56.2%. The underlying etiology was an independent predictor of mortality.

Hypokalemia in acute medical patients: risk factors and prognosis.

OBJECTIVE: Hypokalemia is one of the most common electrolyte disorders in hospitalized patients. It is associated with a high mortality rate among patients with cardiovascular disease. Whether hypokalemia confers a similar risk in an unselected hospitalized population is not well established. METHODS: We conducted a prospective cohort study involving all first-time admissions (n = 11,988) to the Acute Medical Department at Odense University Hospital linking potassium level at admission with registry data on patient characteristics, laboratory data, redeemed prescriptions, and time of death for the period from August 2009 to August 2011. We estimated hazard ratios for all-cause mortality within 0 to 7 days and 8 to 30 days after admission, comparing patients with hypokalemia at admission (plasma [K(+)] level <3.4 mmol/L) with patients with eukalemia at admission ([K(+)] level of 3.4-3.8 mmol/L). RESULTS: Hypokalemia occurred in 16.8% of first-time admissions (n = 2011). It was associated with an adjusted hazard ratio [HR] of 1.34 (95% confidence interval [CI], 0.98-1.85) for 7-day mortality and 1.56 (95% CI, 1.18-3.06) for 8- to 30-day mortality. Among patients with more severe hypokalemia (plasma [K(+)] <2.9 mmol/L), the adjusted HR was 2.17 (95% CI, 1.34-3.49) for 7-day mortality and 1.90 (95% CI, 1.18-3.06) for 8- to 30-day mortality. Prognostic factors for both 7-day and 8- to 30-day mortality among hypokalemic patients were increasing age and Charlson Comorbidity Index, whereas there was no prognostic effect of current diuretic or beta-agonist use. CONCLUSIONS: In a mixed population of hospitalized medical patients, hypokalemia is common, and plasma [K(+)] <2.9 mmol/L is associated with increased 7-day and 8- to 30-day mortality.