There Are Sex Differences in the Demographics and Risk Profiles of Emergency Department (ED) Patients With Atrial Fibrillation and Flutter, but no Apparent Differences in ED Management or Outcomes.

OBJECTIVES: In non-emergency department (ED) settings, women with atrial fibrillation and flutter (AFF) have different presentations, treatments, and outcomes than men: they are older, less likely to be treated with rhythm control strategies or appropriate anticoagulation, and more likely to have strokes. This has not been investigated in ED patients. METHODS: Records from consecutive ED patients from January 1 to December 31, 2009, with electrocardiogram-proven AFF at two urban hospitals were collected. Review of administrative and clinical data identified patient demographics, clinical characteristics, comorbidities, and ED treatments. The regional ED database was queried to determine 30-day and 1-year follow-up visits, and the provincial vital statistics database was referenced to obtain 30-day and 1-year mortality; all outcomes were stratified by sex. The primary outcome, which reflected overall appropriateness of ED care, was the proportion of patients who were discharged home at their index ED visits, who then had unscheduled 30-day ED revisits. Secondary outcomes included the proportion of eligible patients who underwent acute rhythm control strategies and the proportion of high-risk patients who had previously inadequately anticoagulation strategies corrected by the emergency physician. Additional outcomes included the ED length of stay (LOS) and 30-day and 1-year rates of stroke and death. RESULTS: A total of 1,112 records were reviewed: 470 women (42.3%) and 642 men. Women were a median 8 years (interquartile range = 3 to 13 years) older than men, had higher rates of cardiovascular comorbidities, and were more likely to present with atypical symptoms such as weakness or dyspnea. On their index ED visits, 50.2% of women and 41.3% of men were admitted. At 30 days, 39 of 234 (16.7%) women and 55 of 377 (14.6%) men who were discharged at their index ED visits had made revisits, for a risk difference of 2.1% (95% confidence interval = -3.9% to 8.5%). There were no apparent sex differences in the use of acute rhythm control or in the appropriateness of anticoagulation decisions. ED LOS was similar between women and men, as were 30-day and 1-year stroke or death rates. CONCLUSIONS: Female ED AFF patients were older, had more comorbidities, and were more likely to be admitted. However, the overall management and outcomes, including 30-day revisits, appeared to be similar to that of males, indicating that there appeared to be little sex-based discrepancy in ED care and outcomes.

Emergency Department Patients With Atrial Fibrillation or Flutter and an Acute Underlying Medical Illness May Not Benefit From Attempts to Control Rate or Rhythm.

STUDY OBJECTIVE: Although the management and outcomes of emergency department (ED) patients with atrial fibrillation or flutter have been explored, such studies have typically excluded patients with acute underlying medical illnesses. We seek to describe the ED treatment and outcomes of these complex patients with atrial fibrillation or flutter. METHODS: This retrospective descriptive cohort study used an ECG database from 2 urban EDs to identify consecutive ED patients with an ECG demonstrating atrial fibrillation or flutter from January 1, 2009, to December 31, 2009. We categorized patients with atrial fibrillation or flutter as "complex" according to prespecified criteria and then grouped them as being managed with rate or rhythm control attempts, or not. The primary outcome was safety of rate or rhythm control, measured by whether patients had a predefined adverse event or not. The secondary outcome was the success of rate or rhythm control, defined as rate control decreasing the pulse rate by 20 beats/min and successful rhythm control, both within 4 hours of treatment initiation. Descriptive statistics were used to compare the 2 groups. RESULTS: Four hundred sixteen complex patients with atrial fibrillation or flutter were identified. Patients managed with rate or rhythm control were similar in all baseline characteristics and illness distribution to patients who were not managed in this manner. The 135 patients with attempted rate control (105) or rhythm control (30) had 55 adverse events (40.7%; 95% confidence interval [CI] 32.5% to 49.5%), whereas the 281 patients not managed with rate or rhythm control had 20 adverse events (7.1%; 95% CI 4.5% to 10.9%), for a risk difference of 33.6% (95% CI 24.3% to 42.5%) and a relative risk of 5.7 (95% CI 3.6 to 9.1). Twenty of 105 patients (19.1%; 95% CI 12.3% to 28.1%) were successfully rate controlled, whereas 4 of 30 (13.3%; 95% CI 4.4% to 31.6%) were successfully rhythm controlled. CONCLUSION: In ED patients with complex atrial fibrillation or flutter, attempts at rate and rhythm control are associated with a nearly 6-fold higher adverse event rate than that for patients who are not managed with rate or rhythm control. Success rates of rate or rhythm control attempts appear low.

Characteristics and thirty-day outcomes of emergency department patients with elevated creatine kinase.

OBJECTIVES: Rhabdomyolysis, as defined by an elevation in creatine kinase (CK), may lead to hemodialysis and death in emergency department (ED) patients, but the patient characteristics, associated conditions, and 30-day outcomes of patients with CK values over 1,000 U/L have not been described. METHODS: All consecutive ED patients with serum CK values over 1,000 U/L between January 1, 2006, and December 31, 2008, were retrospectively identified from two urban hospitals. Patient characteristics, ED treatment, and ED discharge diagnoses were determined by medical record review. Provincial databases were linked to identify patients who died or were treated with hemodialysis within 30 days. The primary outcome was the combined occurrence of death or need for hemodialysis within 30 days. Secondary outcomes included the incidence of acute kidney injury (AKI) and the proportion of patients with initial estimated glomerular filtration rates (eGFR) > 60 mL/min/1.73 m(2) who died or required hemodialysis. RESULTS: Four-hundred patients were identified, the median age was 50 years (interquartile range [IQR] = 35 to 69 years), and 77% were male, with 35% of patients discharged home from the ED. The most common ED discharge diagnoses were related to recreational drug use, infections, and traumatic or musculoskeletal complaints. Within 30 days, 32 (8.0%, 95% confidence interval [CI] = 5.3% to 11%) experienced primary outcomes, with 18 (4.5%, 95% CI = 2.55% to 6.5%) requiring hemodialysis and 21 deaths (5.3%, 95% CI = 3.1% to 7.4%). AKI occurred in 151 patients (38%, 95% CI = 33% to 43%). Of the 257 patients (64%) with initial eGFRs > 60 mL/min/1.73 m(2) , none required hemodialysis. CONCLUSIONS: In ED patients with initial CK > 1,000 U/L, the incidence of death or hemodialysis was 8% within 30 days. Patients with initial eGFRs > 60 mL/min/1.73 m(2) appear to be at a low risk of these outcomes from rhabdomyolysis.

Missed opportunities for appropriate anticoagulation among emergency department patients with uncomplicated atrial fibrillation or flutter.

STUDY OBJECTIVE: Emergency department (ED) patients with atrial fibrillation or flutter are at risk of stroke, and guidelines recommend anticoagulation for patients with increased cardiovascular risk. Emergency physicians have a unique opportunity to provide appropriate anticoagulation for such patients, and we wished to investigate whether this was accomplished. METHODS: This retrospective cohort study used a database from 2 urban EDs to identify consecutive patients with an ED discharge diagnosis of atrial fibrillation or flutter from April 1, 2006, to March 31, 2010, who were managed solely by the emergency physician. Comorbidities, rhythms, and management were obtained by chart review, and complicated patients (those with an acute underlying medical condition) were excluded by predefined criteria. Patient medications on ED presentations were obtained through the provincial Pharmanet database. Patients were stratified into CHADS 2 (congestive heart failure, hypertension, age > 75, diabetes, stroke/transient ischemic attack) scores, and the primary outcome was the proportion of higher-risk (CHADS 2 score >0) patients who were discharged home with the incorrect anticoagulation by the emergency physician. The secondary outcome was the number of lower-risk (CHADS 2=0) patients who began receiving warfarin by the emergency physician orders. The regional ED database was interrogated to ascertain the number of patients who had a stroke at 30 days. RESULTS: Consecutive patients (1,090) were enrolled and 732 were discharged home with no cardiology consultation (657 fibrillation and 75 flutter). Of 151 higher-risk (CHADS 2 score >0) patients who should have been anticoagulated, 80 (53.0%; 95% confidence interval 44.7% to 61.0%) were discharged home from the ED without appropriate anticoagulation. In this group, 1 patient had an ischemic stroke at 24 days. Among 300 lower-risk patients (CHADS 2 score=0), 25 (8.3%; 95% confidence interval 5.6% to 12.2%) had warfarin initiated. CONCLUSION: In this cohort of ED patients with uncomplicated atrial fibrillation or flutter who were discharged without cardiology involvement, many were not appropriately anticoagulated before ED arrival, and more than half of such patients did not appear to have corrective measures initiated by the emergency physician. This may represent a potential opportunity to improve patient care and outcomes.

Thirty-day and 1-year outcomes of emergency department patients with atrial fibrillation and no acute underlying medical cause.

STUDY OBJECTIVE: Atrial fibrillation is the most common dysrhythmia observed in the emergency department (ED), yet there is little research describing long-term outcomes after ED management. Our objective is to describe ED treatment approach, conversion success rates, ED adverse events, and 30-day and 1-year outcomes for a cohort of ED patients with atrial fibrillation and no acute underlying medical cause. METHODS: This retrospective cohort study used a database from 2 urban EDs to identify consecutive patients with an ED discharge diagnosis of atrial fibrillation from April 1, 2006, to March 31, 2010. Comorbidities, rhythms, management, and immediate outcomes were obtained by manual chart review, and patients with an acute underlying medical condition were excluded by predefined criteria. Patients were stratified into 5 groups according to ED management: electrocardioversion, chemical cardioversion, spontaneous cardioversion, rate control only, and no arrhythmia-specific treatment. To identify deaths, strokes, and ED revisits within 1 year, each patient's unique provincial health number was linked to the provincial vital statistics registry and the regional ED database. Primary outcome was the number of patients having either stroke or death of any cause at 30 days, stratified by treatment group. RESULTS: Of 927 consecutive eligible patients, 121 (13.1%) converted to sinus rhythm before ED intervention, 357 (38.5%) received ED rhythm control, and 449 (48.4%) did not receive rhythm control. Overall, 142 of 927 patients (15.3%) were admitted to the hospital at the index ED visit. At 30 days, 2 patients had a stroke and 5 died (combined outcome rate 0.8%; 95% confidence interval 0.3% to 1.6%). All 7 of these patients were admitted at the index ED visit. CONCLUSION: In this large cohort of ED patients with atrial fibrillation and no acute underlying medical cause, the 30-day rate for stroke or death was less than 1%. Nearly 85% of patients-regardless of treatment approach or conversion to sinus rhythm-were discharged at the index ED visit, and none of these patients had a stroke or died at 30 days.

Regulation of murine telomere length by Rtel: an essential gene encoding a helicase-like protein.

Little is known about the genes that regulate telomere length diversity between mammalian species. A candidate gene locus was previously mapped to a region on distal mouse Chr 2q. Within this region, we identified a gene similar to the dog-1 DNA helicase-like gene in C. elegans. We cloned this Regulator of telomere length (Rtel) gene and inactivated its expression in mice. Rtel(-/-) mice died between days 10 and 11.5 of gestation with defects in the nervous system, heart, vasculature, and extraembryonic tissues. Rtel(-/-) embryonic stem cells showed telomere loss and displayed many chromosome breaks and fusions upon differentiation in vitro. Crosses of Rtel(+/-) mice with Mus spretus showed that Rtel from the Mus musculus parent is required for telomere elongation of M. spretus chromosomes in F1 cells. We conclude that Rtel is an essential gene that regulates telomere length and prevents genetic instability.