Cardioversión en la fibrilación auricular de reciente comienzo / Cardioversion in recent onset atrial fibrillation

Objetivos: Este estudio analiza el control del ritmo en los servicios de urgencias (SUH) y sus resultados en pacientes con fibrilación auricular (FA) de reciente comienzo, para identificar áreas de mejora en el manejo. Método: Estudio multicéntrico, observacional, prospectivo y transversal desarrollado en 124 SUH representativos del sistema sanitario español basado en el registro HERMES-AF (estrategias de manejo en el servicio de urgencias hospitalario de la FA) del 23 de mayo al 5 de junio de 2011. Se incluyeron pacientes con FA sintomática con menos de 48 h de evolución en los cuales se tomó la decisión de restaurar el ritmo sinusal. Resultados: Se incluyeron 337 pacientes, se optó por cardioversión farmacológica en 311 pacientes (92,3%), y por cardioversión eléctrica en 52 (15%), la mitad de los casos tras fracaso de los fármacos. Se obtuvo ritmo sinusal (RS) en 278 pacientes (82,5%) y el alivio de los síntomas en 297 (94%), con una tasa de efectos adversos del 0,9%, ninguno grave. Amiodarona se asoció de manera independiente a una menor tasa de RS al alta (OR = 0,442; IC 95% 0,238-0,823; p = 0,01), al contrario que la cardioversión eléctrica (OR = 4,0; IC 95% 1,2-13,3; p = 0,024). Los fármacos I-C se asociaron con una mayor proporción de altas en < 6 h (OR 2,6; IC 95% 1,6-4,3; p < 0,001) y amiodarona con más estancias prolongadas de > 24 h (OR 2,7, IC 95% 1,5-4,8; p < 0,003). Conclusiones: En los SUH, la restauración del RS en la FA de reciente comienzo es segura, efectiva y asocia beneficios clínicos para los pacientes. Reemplazar amiodarona por técnicas más efectivas y rápidas como la cardioversión eléctrica o los fármacos I-C es un área de mejora de la calidad asistencial

Objectives: To analyze heart rate control in hospital emergency departments and outcomes in patients with recent onset atrial fibrillation (AF) so that targets for improvement can be identified. Methods: Multicenter, prospective observational cross-sectional study in a representative sample of 124 hospitals of the Spanish health services, based on records in the HERMES-AF database (Hospital Emergency Department Management Strategies for AF) for May 23 to June 5, 2011. Patients with symptomatic AF within 48 hours of onset were enrolled when the decision was made to attempt restoration of sinus rhythm. Results: We included 337 patients. Chemical cardioversion was used in 311 (92.3%) and electrical cardioversion in 52 (15%), after drugs had failed in half the cases. Sinus rhythm was restored in 278 patients (82.5%), and symptoms resolved in 94%. Adverse effects were recorded in 0.9% but none were serious. Amiodarone was independently associated with a lower rate of restored sinus rhythm (odds ratio [OR], 0.442; 95% CI, 0.238-0.823; P=.01) than electrical cardioversion (OR, 4.0; 95% CI, 1.2-13.3; P=.024). The use of class Ic antiarrhythmic agents was associated with a higher percentage of discharges in less than 6 hours (OR, 2.6; 95% CI, 1.6-4.3; P<.001), and amiodarone was associated with hospital stays longer than 24 hours (OR, 2.7; 95% CI, 1.5-4.8; P<.003). Conclusions: Emergency department restoration of sinus rhythm in patients with AF is safe, effective, and associated with clinical benefits. Quality of care could be improved by replacing the use of amiodarone with faster and more effective treatments such as electrical cardioversion or the use of class Ic agents

Cardioversion in recent onset atrial fibrillation. / Cardioversión en la fibrilación auricular de reciente comienzo.

OBJECTIVES: To analyze heart rate control in hospital emergency departments and outcomes in patients with recent onset atrial fibrillation (AF) so that targets for improvement can be identified. MATERIAL AND METHODS: Multicenter, prospective observational cross-sectional study in a representative sample of 124 hospitals of the Spanish health services, based on records in the HERMES-AF database (Hospital Emergency Department Management Strategies for AF) for May 23 to June 5, 2011. Patients with symptomatic AF within 48 hours of onset were enrolled when the decision was made to attempt restoration of sinus rhythm. RESULTS: We included 337 patients. Chemical cardioversion was used in 311 (92.3%) and electrical cardioversion in 52 (15%), after drugs had failed in half the cases. Sinus rhythm was restored in 278 patients (82.5%), and symptoms resolved in 94%. Adverse effects were recorded in 0.9% but none were serious. Amiodarone was independently associated with a lower rate of restored sinus rhythm (odds ratio [OR], 0.442; 95% CI, 0.238-0.823; P=.01) than electrical cardioversion (OR, 4.0; 95% CI, 1.2-13.3; P=.024). The use of class Ic antiarrhythmic agents was associated with a higher percentage of discharges in less than 6 hours (OR, 2.6; 95% CI, 1.6-4.3; P< .001), and amiodarone was associated with hospital stays longer than 24 hours (OR, 2.7; 95% CI, 1.5-4.8; P< .003). CONCLUSION: Emergency department restoration of sinus rhythm in patients with AF is safe, effective, and associated with clinical benefits. Quality of care could be improved by replacing the use of amiodarone with faster and more effective treatments such as electrical cardioversion or the use of class Ic agents.

OBJETIVO: Este estudio analiza el control del ritmo en los servicios de urgencias (SUH) y sus resultados en pacientes con fibrilación auricular (FA) de reciente comienzo, para identificar áreas de mejora en el manejo. METODO: Estudio multicéntrico, observacional, prospectivo y transversal desarrollado en 124 SUH representativos del sistema sanitario español basado en el registro HERMES-AF (estrategias de manejo en el servicio de urgencias hospitalario de la FA) del 23 de mayo al 5 de junio de 2011. Se incluyeron pacientes con FA sintomática con menos de 48 h de evolución en los cuales se tomó la decisión de restaurar el ritmo sinusal. RESULTADOS: Se incluyeron 337 pacientes, se optó por cardioversión farmacológica en 311 pacientes (92,3%), y por cardioversión eléctrica en 52 (15%), la mitad de los casos tras fracaso de los fármacos. Se obtuvo ritmo sinusal (RS) en 278 pacientes (82,5%) y el alivio de los síntomas en 297 (94%), con una tasa de efectos adversos del 0,9%, ninguno grave. Amiodarona se asoció de manera independiente a una menor tasa de RS al alta (OR = 0,442; IC 95% 0,238-0,823; p = 0,01), al contrario que la cardioversión eléctrica (OR = 4,0; IC 95% 1,2-13,3; p = 0,024). Los fármacos I-C se asociaron con una mayor proporción de altas en < 6 h (OR 2,6; IC 95% 1,6-4,3; p < 0,001) y amiodarona con más estancias prolongadas de > 24 h (OR 2,7, IC 95% 1,5-4,8; p < 0,003). CONCLUSIONES: En los SUH, la restauración del RS en la FA de reciente comienzo es segura, efectiva y asocia beneficios clínicos para los pacientes. Reemplazar amiodarona por técnicas más efectivas y rápidas como la cardioversión eléctrica o los fármacos I-C es un área de mejora de la calidad asistencial.

Benefits of Rhythm Control and Rate Control in Recent-onset Atrial Fibrillation: The HERMES-AF Study.

BACKGROUND: Although rhythm control has failed to demonstrate long-term benefits over rate control in longstanding episodes of atrial fibrillation (AF), there is little evidence concerning recent-onset ones. We analyzed the benefits of rhythm and rate control in terms of symptoms alleviation and need for hospital admission in patients with recent-onset AF. METHODS: This was a multicenter, observational, cross-sectional study with prospective standardized data collection carried out in 124 emergency departments (EDs). Clinical variables, treatment effectiveness, and outcomes (control of symptoms, final disposition) were analyzed in stable patients with recent-onset AF consulting for AF-related symptoms. RESULTS: Of 421 patients included, rhythm control was chosen in 352 patients (83.6%), a global effectiveness of 84%. Rate control was performed in 69 patients (16.4%) and was achieved in 67 (97%) of them. Control of symptoms was achieved in 396 (94.1%) patients and was associated with a heart rate after treatment ≤ 110 beats/min (odds ratio [OR] = 14.346, 95% confidence interval [CI] = 3.90 to 52.70, p < 0.001) and a rhythm control strategy (OR = 2.78, 95% CI = 1.02 to 7.61, p = 0.046). Sixty patients (14.2%) were admitted: discharge was associated with a rhythm control strategy (OR = 2.22, 95% CI = 1.20-4.60, p = 0.031) and admission was associated with a heart rate > 110 beats/min after treatment (OR = 29.71, 95% CI = 7.19 to 123.07, p < 0.001) and acute heart failure (OR = 9.45, 95% CI = 2.91 to 30.65, p < 0.001). CONCLUSION: In our study, recent-onset AF patients in whom rhythm control was attempted in the ED had a high rate of symptoms' alleviation and a reduced rate of hospital admissions.

Stroke prophylaxis in atrial fibrillation: searching for management improvement opportunities in the emergency department: the HERMES-AF study.

STUDY OBJECTIVE: We determine the prevalence of stroke prophylaxis prescription in emergency department (ED) patients with atrial fibrillation and the factors associated with a lack of prescription of anticoagulation in high-risk patients without contraindications. METHODS: This was a multicenter, observational, cross-sectional study with prospective standardized data collection carried out in 124 Spanish EDs. Clinical variables, risk factors for stroke, type of prophylaxis prescribed, and reasons for not prescribing anticoagulation in high-risk patients (congestive heart failure/left ventricular dysfunction, hypertension, age >75 years, diabetes and previous stroke/transient ischemic attack/systemic embolism [CHADS2] score ≥2 and the congestive heart failure/left ventricular dysfunction, hypertension, age >75 years, diabetes, previous stroke/transient ischemic attack/systemic embolism, vascular disease age 65 to 74 years and sex category [CHA2DS2-VASc] score ≥2) without contraindications were collected. RESULTS: Of 3,276 patients enrolled, 71.5% were at high risk according to CHADS2; 89.7% according to CHA2DS2-VASc. At discharge from the ED, 2,255 patients (68.8%) were receiving anticoagulants, 1,691 of whom (75%) were high-risk patients. Of the 1,931 patients discharged home, anticoagulation was prescribed for 384 patients (19.9%) de novo and for 932 patients (48.3%) previously receiving anticoagulation. The main reasons for not prescribing anticoagulation to eligible patients were considering antiplatelet therapy as adequate prophylaxis (33.1%), advanced age (15%), and considering stroke risk as low (8.3%). Advanced age (odds ratio 0.46; 95% confidence interval 0.30 to 0.69) and female sex (odds ratio 0.50; 95% confidence interval 0.36 to 0.71) were significantly associated with the lack of prescription of anticoagulation to eligible patients. CONCLUSION: In Spain, most patients with atrial fibrillation treated in EDs who do not receive anticoagulation are at high risk of stroke, with relevant differences with regard to the risk stratification scheme used. Anticoagulation is underused, mainly because the risk of stroke is underestimated by the treating physicians and the benefits of antiplatelets are overrated, principally in female patients and the elderly. Efforts to increase the prescription of anticoagulation in these patients appear warranted.

Antiplatelet therapy in endovascular surgery: the RENDOVASC study.

BACKGROUND: Antiplatelet treatment prevents cardiovascular events and thrombosis during the endovascular surgery procedure. The aim of this study is to analyze the different antiplatelet treatment used in endovascular procedures in Spain. METHODS: In this investigation we included observational, retrospective, and multicenter study patients who underwent arterial endovascular therapy in 2006 or in the first 3 months of 2007, and follow-up of at least 1 year. The following data were collected: the usual epidemiologic variables, history of cardiovascular disease (coronary, cerebrovascular, or peripheral artery disease), risk factors, endovascular procedure performed, blood pressure, ethiology of arterial disease, the pre-operative antiaggregant treatment, and antiplatelet therapy used at 1 month and 1 year after the procedure. RESULTS: A total of 1,557 patients were evaluated, of whom 84.3% were male. In addition 72.1% were hypertensive, 53.1% dyslipidemic, and 43.3% diabetic. From these patients, 32.6% presented with ischemic cardiomyopathy, 17.9% had a cerebral vascular history, and 35.3% had peripheral arterial disease. The most common etiology was occlusive disease (76.9%), the most commonly treated arterial sector was iliac (33.4%), and the most frequent procedure was stent angioplasty (46.9%). In the preoperative period, 75.1% of the patients were given antiplatelet therapy (89% simple antiplatelet treatment), 62.9% in the perioperative period, and 93.8% at 1 month after surgery (37.3% double antiaggregation). Antiplatelet treatment was administered previously to 86.2% of patients with history of cerebrovascular disease and to 88% of those with coronary disease. In the femoropopliteal sector 76.1% patients were receiving antiaggregation treatment before the procedure (11.1% double). However, 1 month later, double antiaggregation therapy was increased (45.3%), especially in the angioplasty and stent. In the iliac sector, 43.1% of patients with arterial stenosis and 38.2% of patients with complete arterial occlusion treated with angioplasty and stent continued receiving double antiaggregation 1 month after the procedure. In the carotid territory, 65.7% of patients treated with stent were receiving double antiplatelet treatment 1 month after the procedure. CONCLUSIONS: We believe it is necessary to create consensus committees to perform clinical practice evidence-based guidelines to formalize antiaggregation treatment in endovascular procedures.