Burden of atrial fibrillation: a retrospective review of patients presenting to acute medical services.

BACKGROUND: Atrial fibrillation (AF) is a major risk factor for stroke and is associated with increased stroke severity and greater morbidity and mortality. Anticoagulation is highly effective for preventing episodes of thromboembolism but remains under-utilised. AIMS: The aim of this review was to estimate the short-term risk of thromboembolic events in patients presenting with an acute medical illness, to assess rates of anticoagulation in eligible patients with AF and to describe physician decisions when prescribing anticoagulation in a hospital setting. METHODS: A retrospective cohort analysis of patients with AF presenting to acute medical services at Wellington Regional Hospital between 1 January 2012 and 31 December 2012 was performed. RESULTS: A total of 751 patient presentations with AF was identified; 613 unique patient encounters were eligible for analysis, and 38.8% of patients with a CHA2 DS2 -VASc score ≥2 were discharged after anticoagulation. The mean CHA2 DS2 -VASc score was 4.03 (SD = 1.94). The CHA2 DS2 -VASc score was not associated with being started on anticoagulation, odds ratio 1.16 (95% confidence interval = 0.83-1.61), P = 0.38, but age by decade older was associated with a reduced likelihood of being started on anticoagulation, odds ratio 0.61 (95% confidence interval = 0.41-0.89), P = 0.01. In untreated patients with a CHA2 DS2 -VASc score ≥2, the most frequently documented reasons not to initiate anticoagulation were decision deferred to the primary care physician, 15.6%; fall risk or frailty, 7.2%; and high bleeding risk, 6.6%. However, no reason was documented in 56.9%. The thromboembolic rate in patients discharged without anticoagulation within 3 months of presentation to acute medical services was 7/330 (2.1%). CONCLUSION: Anticoagulation for stroke prevention in AF remains under-utilised in eligible patients presenting to acute medical services at a tertiary-level hospital.

Seizure management at Auckland City Hospital Emergency Department between July and December 2009: time for a change?

AIMS: To assess the management of epileptic seizures and status epilepticus in adult patients at Auckland City Hospital emergency department. This information will form the basis of future seizure management protocols and further research on the management of status epilepticus. METHODS: The prehospital and acute hospital management of all adult seizure patients seen between 1 July 2009 and 31 December 2009 was reviewed with respect to seizure type, presence of first seizure, pre-existing epilepsy diagnosis and disposition from the emergency department. RESULTS: Two hundred and fifty-five seizure events were identified in 227 patients. Nineteen patients presented twice during the study period and three patients presented three or more times. Generalised seizures were much more common than focal seizures. There were 75 presentations with first seizure (29.4%). Thirty-seven patients (49.3%) with a first seizure received treatment with an anti-epileptic drug. Status epilepticus occurred on 12 occasions (4.7%) with only three patients receiving lorazepam as treatment. The majority of seizure patients were managed by emergency department staff (58.4%) while general medicine (17.6%) and neurology (11.8%) teams managed fewer patients. Phenytoin was used in 56 patients (22%) with the majority (n= 43) receiving intravenous phenytoin. Many of the patients who received intravenous phenytoin were not subsequently discharged on that medication (46%). CONCLUSIONS: More patients than would be expected received treatment after their first seizure. Phenytoin was a widely used anti-epileptic drug. There was a wide variability in the management of status epilepticus, and intravenous lorazepam was underutilised.