Presentation, Treatment and Long-Term Outcomes of a Multidisciplinary Acute Atrial Fibrillation Pathway: A 12-Month Follow-Up Study
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Heart, Lung and Circulation (2022) 31, 216–223 ORIGINAL ARTICLE
1443-9506/21/$36.00
https://doi.org/10.1016/j.hlc.2021.05.102
Presentation, Treatment and Long-Term
Outcomes of a Multidisciplinary Acute
Atrial Fibrillation Pathway: A 12-Month
Follow-Up Study
Ibrahim S. Al-Busaidi, MBChB a,b,*, Geoffrey C. Clare, MBChB a,b,
Laura R. Joyce, MBChB c,d, Scott Pearson, MBChB d,
John Lainchbury, MD a,b, Martin Than, MBBS d,
Richard W. Troughton, PhD a,b
a
Department of Medicine, University of Otago, Christchurch, New Zealand
b
Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
c
Department of Surgery, University of Otago, Christchurch, New Zealand
d
Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
Received 11 February 2021; received in revised form 1 April 2021; accepted 16 May 2021; online published-ahead-of-print 29 June 2021
Aim Atrial fibrillation/flutter (AF/AFL) is associated with high rates of emergency department (ED) visits and
acute hospitalisation. A recently established multidisciplinary acute AF treatment pathway seeks to avoid
hospital admissions by early discharge of haemodynamically stable, low risk patients from the ED with
next-working-day return to a ward-based AF clinic for further assessment. We conducted a preliminary
analysis of the clinical outcomes of this pathway.
Methods We retrospectively reviewed clinical records of all patients assessed at the AF clinic at Christchurch
Hospital, New Zealand, over a 12-month period. Data related to presentation, patient characteristics,
treatment, and 12-month outcomes were analysed.
Results A total of 143 patients (median age 65, interquartile range: 57–74 years, 59% male, 87% European) were
assessed. Of these, 87 (60.8%) presented with their first episode of AF/AFL. Spontaneous cardioversion
occurred in 41% at ED discharge, and this increased to 73% at AF clinic review. Electrical cardioversion was
subsequently performed in 16 patients (11.2%), and 16 (11.2%) ultimately required hospital admission
(eight to facilitate electrical cardioversion). At a median of 1 day, 83.9% were discharged from the AF clinic
in sinus rhythm. During 12-month follow-up, there were 25 AF-related hospitalisations (20 patients, 14%)
and one patient underwent electrical cardioversion; additionally, one patient had had a stroke and eight
had bleeding complications giving a combined outcome rate of 6.3%.
Conclusion Utilising a rate-control strategy with ED discharge and early return to a dedicated AF clinic can safely
prevent the majority of hospitalisations, avert unnecessary procedures, and facilitate longitudinal care.
Keywords Atrial fibrillation Atrial flutter Cardioversion Emergency department Oral anticoagulation Risk
stratification New Zealand
*Corresponding author at: Department of Cardiology, Christchurch Hospital and Department of Medicine, University of Otago, 2 Riccarton Avenue, PO Box 4345,
Christchurch 8140, New Zealand; Email: ibrahim.al-busaidi@otago.ac.nz; Twitter: @IbzAlBusaidi
Ó 2021 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ).
Published by Elsevier B.V. All rights reserved.
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Introduction Acute AF Pathway
Christchurch Hospital is an academic general hospital and
Atrial fibrillation (AF) is the most common sustained
tertiary referral centre with 833 bed capacity serving a
abnormal rhythm in adults and represents a major global
catchment population of 558,830. It has the principal regional
public health challenge [1,2]. Recent estimates from New
ED and the only regional specialist cardiology service. Ac-
Zealand indicate an overall AF prevalence of around 2–3%
cording to hospital administrative data, around 850 patients
[3,4], and this rises to at least 5% in persons aged 65 years or
have a hospital admission within the cardiology department
older [3]. AF is strongly associated with increased morbidity
annually with a primary diagnosis of AF/flutter (AFL). In
rates, especially stroke, heart failure, and dementia, reduced
order to optimise patient care, reduce admissions, and also to
quality of life, and increased all-cause mortality [1,2].
reduce unnecessary acute cardioversions in the ED, an inter-
Atrial fibrillation represents a major economic burden on
departmental acute AF guideline-based clinical pathway was
health care systems around the world with hospitalisations
developed by the cardiology service in 2015 in collaboration
and AF-related complications, such as stroke, heart failure
with emergency medicine and primary care at the Canter-
and myocardial infarction, being the primary cost drivers
bury District Health Board. The structure and content of the
[5,6]. It accounts for 0.5% of all emergency department (ED)
AF pathway were agreed upon through discussion and
visits [7], and up to 40% of primary AF patients are hospi-
consensus between the three specialties. Before imple-
talised every year [2]. Increasing numbers of integrated AF-
mentation, education was provided to ED and cardiology
specific care pathways and dedicated clinics have been
medical and nursing staff about the new acute AF treatment
implemented [2,8] with associated improvement in adher-
pathway structure and process.
ence to clinical guidelines and reduction in length of stay and
Content of the AF pathway includes an AF/AFL care map,
AF-related hospitalisation [9–13].
written guidelines on initial ED and AF clinic assessment,
We recently established an evidence-based [2,8], multi-
investigations and management, clinical decision support
disciplinary acute AF clinical pathway that seeks to avoid
scores (thromboembolic [CHA2DS2-VASc] and bleeding
hospital admissions by early discharge of haemodynamically
[HAS-BLED1] risk assessment), nurse-administered patient
stable, low risk patients from the ED with next-working-day
education, and follow-up care. Patients are initially assessed
return to a ward-based AF clinic for further assessment. Prior
and managed in the ED by cardiology department and/or
evaluation of the acute AF pathway showed short-term im-
ED medical staff which includes rate-control medications
provements in adherence to guideline recommendations
and anticoagulation therapy. Patients who convert to sinus
(e.g., thromboembolic and bleeding risk assessment, appro-
rhythm or achieve a heart rate of 110 beats per minute with
priate anticoagulation) and reduced hospitalisation [14,15].
relief of AF-related symptoms and remain haemodynami-
However, data on long-term outcomes are lacking.
cally stable are discharged home with a review scheduled for
In this preliminary analysis, we sought to evaluate the
the following working day at the acute AF clinic [Appendix].
long-term clinical outcomes for patients managed under the
The acute AF clinic is a low-acuity outpatient facility
acute AF pathway. Our aims were two-fold: (1) assess de-
located on the cardiology ward, Christchurch Hospital, and
mographic and clinical characteristics of AF pathway pa-
receives referrals from general practice or the ED. The clinic
tients, and (2) examine risk assessment, treatment, discharge
is staffed by rotating medical registrars (cardiology and
rhythm, and 12-month outcomes including readmission rate,
non-cardiology specialty trainees/residents) as the primary
thromboembolic and bleeding events, and all-cause
providers and registered nurses with supervision by a
mortality.
cardiologist. It provides clinical and diagnostic evaluation,
individualised risk-factor management, and treatment for
patients under the AF pathway. All patients receive educa-
Materials and Methods tion on AF/AFL, risk factor modification (e.g., obesity, hy-
pertension, obstructive sleep apnoea, and alcohol
consumption), treatment and intervention options, dose
Study Population titration and management of recurrent episodes. During
This was a cross-sectional retrospective cohort study con- clinic review, a treatment strategy (rate or rhythm control) is
ducted at the acute AF clinic, Cardiology ward, Christchurch initiated and patients are either admitted to the ward for
Hospital, New Zealand. We reviewed clinical records of all further assessment and management (e.g., unstable patients
consecutive patients evaluated at the clinic during the period with symptomatic AF/AFL or those requiring acute direct
between 1 May 2016 and 30 April 2017. As this was an current cardioversion [DCCV]) or discharged back to their
observational study of anonymised data collected as part of a general practitioner with/without outpatient cardiology
service improvement/quality assurance project, formal follow-up. Additional follow-up investigations/in-
ethical approval was not required according to the New terventions may be arranged including echocardiography,
Zealand National Ethics Advisory Committee guidelines electrocardiograph (ECG) Holter monitoring, and elective
[16]. DCCV.
1
Hypertension, Abnormal renal and liver function, Stroke, Bleeding, Labile INR, Elderly, Drugs or alcohol.
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Data Collection majority of results were presented as descriptive statistics (i.e.,
A prospective database of all patients assessed at the AF number [percentage], mean 6 standard deviation [if normally
clinic is kept by clinic staff. Patients who did not meet the AF distributed], and median with interquartile range, IQR [if non-
pathway criteria for discharge from the ED, had secondary normally distributed]). All statistical analyses were performed
AF/AFL or other atrial arrhythmias (e.g., supraventricular using the Statistical Package for the Social Sciences for Win-
tachycardia), were admitted to the hospital, or did not attend dows Version 20.0 (IBM Corp, Armonk, NY, USA).
the AF clinic follow-up review were excluded. Paper and
electronic medical records of identified patients were
retrieved and retrospectively reviewed. Demographic and Results
clinical data including age, gender, ethnicity, and comor-
bidities were collected. Obesity was defined as a body mass Patient Characteristics
index (BMI) ≥30 kg/m2. Information related to initial ED Figure 1 shows a general flow diagram of the AF patient care
treatment, thromboembolic (CHA2DS2-VASc) and bleeding pathway (1 May 2016 to 30 April 2017). Overall, 147 patients
(HAS-BLED) risk assessment, AF clinic treatment including were identified in the AF clinic database; four patients had
anticoagulation prescribing, follow-up investigations, car- other atrial tachyarrhythmias, and thus were excluded from
dioversion, outpatient cardiology follow-up, and 12-month the analysis. A total of 143 patients were managed under the
clinical outcomes were analysed. Presenting/discharge acute AF pathway. This represented 19.8% of total number of
rhythm was assessed in the ED and AF clinic using 12-lead patients admitted to cardiology during the study period with
ECG. Spontaneous cardioversion was defined as the con- a primary diagnosis of AF/AFL; n=721. The median age was
version of AF/AFL to sinus rhythm before or after the 65 years (IRQ: 57-74, range 22–88). The cohort was pre-
administration of only rate-control drugs (beta blockers dominately male (59%), European (87%), with a significant
excluding sotalol, calcium channel blockers, or digoxin). The number being obese (40%). Cardiovascular comorbidities
primary outcome was a combination of AF-related hospi- were common, and 38.5% and 3.5% of patients had a history
talisation (defined as admission to the cardiology ward with of AF and AFL at the time of ED visit, respectively. The
a primary diagnosis of AF/AFL), stroke, bleeding events or clinical and demographic characteristics of patients managed
death from any cause within the 12-month follow-up period. under the AF pathway are presented in Table 1.
Statistical Analysis Initial ED Assessment
All data were entered into a predesigned Excel spreadsheet At initial assessment in the ED, AF was the most common
Version 2016 (Microsoft Corp., Redmond, WA, USA). The rhythm (n=129, 90.2%) with 87 patients (60.8%) presenting
Figure 1 Flow diagram of AF patient care pathway (1 May 2016 to 30 April 2017).
Abbreviations: AF, atrial fibrillation; AFL, atrial flutter; ED, emergency department; SR, sinus rhythm.
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Table 1 Characteristics of study patients (May 2016– Table 2 Emergency department treatment and
April 2017), n=143. outcomes (n=143).
Characteristicsa N % Characteristics N %
Age, yr 65 (57-74) Rhythm at initial presentation
Male sex 85 59 AF 129 90.2
Ethnicity AFL 14 9.8
Asian 4 2.8 Types of AF/AFL
European 125 87.4 First presentation 87 60.8
M
aori 6 4.2 Paroxysmal 54 37.8
Middle Eastern/Latin American/ 6 4.2 Persistent 1 0.7
African Permanent 1 0.7
Pacific 2 1.4 Treatment
Body mass index (kg/m2) 28 (25-32) Rate control medications 128 89.5
Obese 59 41.3 Metoprolol 104 81.3
Smoking status Diltiazem 15 11.7
Current 13 9.1 Digoxin 2 1.6
Ex-smoker 43 30.1 Metoprolol and digoxin 7 5.5
Never 87 60.8 Oral anticoagulation therapy 81 56.6
History of underlying disease Dabigatran 74 91.4
Hypertension 85 59.4 Warfarin 7 8.6
Diabetes mellitus 16 11.2 DCCV 0 0
Obstructive sleep apnoea 6 4.2 Treatment outcomes
Chronic obstructive lung disease 5 3.5 Discharge rhythm
Asthma 11 7.7 SR 59 41.3
Thyroid disorders (hypo- and 22 15.4 AF 72 50.3
hyperthyroidism) AFL 12 8.4
Anaemia 5 3.5 Disposition
Congestive heart failure 13 9.1 Discharge from ED 142 99.3
Valvular heart disease 11 7.7 Transferred to AF clinic 1 0.7
Coronary artery disease 25 17.5
Angiography 30 21.0 Abbreviations: AF, atrial fibrillation; AFL, atrial flutter; CD, cardiology
Percutaneous coronary intervention 16 11.2 department; DCCV, direct current cardioversion; ED, emergency depart-
Coronary artery bypass grafting 4 2.8 ment; SR, sinus rhythm.
Pacemaker implantation/CRT/ICD 0 0
Previous stroke/transient ischaemic 8 5.6
attack
discharge, 59 patients (41.3%) converted to sinus rhythm
Previous AF 55 38.5
while 84 (58.7%) remained in rate-controlled AF/AFL; 51 of
Previous AFL 5 3.5
the latter group (60.7%) were prescribed anticoagulation. Of
Previous AF/AFL ablation 6 4.2
those who converted to sinus rhythm in ED, 30 (51%) were
Previous DCCV 22 15
prescribed oral anticoagulation in ED. The median
Echocardiogram (past 12 mo) 16 11
CHA2DS2-VASc in the group was 2 and 64 % (n=38) had a
Left ventricular ejection fraction (%) 61.4 (59-67.1)
score 2. Of these, 30 patients, 26 (87%) were prescribed
Left atrium size (cm2) 19.1 (17-22.6)
long-term anticoagulation after AF clinic review. The median
CHA2DS2-VASc among patients prescribed long-term anti-
Abbreviations: AF, atrial fibrillation; AFL, atrial flutter; CRT, cardiac
coagulation was 3 (range 1–5) and 90% had a score 2.
resynchronisation therapy; DCCV, direct current cardioversion; ED,
emergency department; ICD, implantable cardioverter–defibrillator.
Almost all patients were discharged home after ED
a
Categorical variables are described as frequencies (percentages) and assessment and treatment (99.3%); only one patient who
continuous variables using median and 25th-75th percentile range. presented to the ED after midnight was admitted directly to
the clinic (Table 2).
with their first episode of AF/AFL. Rate-control medications AF Clinic
were prescribed to 128 patients (89.5%) while 81 (56.6%) The median time between ED presentation and AF clinic
received anticoagulation (74 dabigatran and 7 warfarin). No review was 1 day (range, 0–5; 78.3% seen within 1 day and
patients underwent electrical cardioversion in the ED. At ED 97.2% within the next working/business day). At return to
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the AF clinic, conversion to sinus rhythm had occurred
spontaneously in 42 of the 84 patients (50%) with rate- Table 3 Acute AF clinic assessment and treatment
(n=143).
controlled AF/AFL at ED discharge. Thromboembolic
(CHA2DS2-VASc) and bleeding (HAS-BLED) risk scores Variablea N %
were documented in 55.2% and 8.4%, respectively. Eighty-
Time between ED presentation and 1 (1-1)
nine (89) patients (62.2% of the total cohort) had an
clinic review (d)
increased thromboembolic risk as defined by a CHA2DS2-
Seen within 1 d 112 78.3
VASc score of 2. During clinic assessment and manage-
Risk stratification
ment, long-term rate-control medications were prescribed to
CHA2DS2-VASc score documented 79 55.2
104 patients (72.7%) which included beta-adrenergic receptor
CHA2DS2-VASc score (n=79) 2 (1-3)
blocking agents (n=86), non-dihydropyridine calcium-chan-
CHA2DS2-VASc calculatedb (n=143) 2 (1-3)
nel antagonists (n=12), digoxin (n=1) or a combination of
Score 2 89 62.2
these medications (n=5). Rhythm-control drugs were pre-
Score 1 54 37.8
scribed to 14 (9.8%) patients (two for pharmacological car-
HAS-BLED documented 12 8.4
dioversion and 12 for the maintenance of sinus rhythm).
HAS-BLED score (n=12) 1 (0-1.75)
Anticoagulation therapy was provided to 83 (58%) of all
HAS-BLED calculatedb (n=143) 1 (0-2)
patients (71 dabigatran and 12 warfarin) and 71 (89%) of
Clinic treatment
those with CHA2DS2-VASc 2 or more (Table 3). Electrical
Rate control medications 104 72.7
cardioversion (n=16, 11.2%) with same-day discharge was
Metoprolol 85 81.7
performed in eight patients (5.6%). No patients were listed
Diltiazem 11 10.6
directly for catheter ablation therapy. Sixteen (16) patients
Digoxin 1 1
(11.2%) required direct hospital admission (14 AF, one AFL,
Bisoprolol 1 1
one sinus rhythm); eight with persistent (heart rate of .110
Verapamil 1 1
beats per min), symptomatic AF/AFL who required further
Metoprolol and digoxin 4 3.8
period of observation and/or inpatient management.
Carvedilol and digoxin 1 1
At the end of AF clinic management, 120 patients
Rhythm control medications 14 9.8
(83.9%) were in sinus rhythm (including 16 patients
Amiodarone 1 7.1
who underwent DCCV and three of the eight who
Flecainide 4 28.6
were admitted with symptomatic, unstable AF/AFL)
Sotalol 9 64.3
(Figure 1 and Table 3). Spontaneous reversion to sinus
Oral anticoagulation therapy 83 58
rhythm occurred in 104 (72.7%). Guideline-appropriate
Dabigatran 71 85.5
oral anticoagulation was provided to 71 of 89 pa-
Warfarin 12 14.5
tients (79.8%) with a CHA2DS2-VASc score of 2 or
DCCV 8 5.6
higher. Of the remainder who were discharged from
TOE-DCCV 8 5.6
the AF clinic without long-term anticoagulant pre-
AF clinic rhythm
scription (n=18, 20.2%), one was a male patient
Admission rhythm
referred with a first episode AF who was prescribed
SR 101 70.6
aspirin due to a recent-onset haematuria and the other
AF 37 25.9
17 patients had no documented contraindications. Of
AFL 5 3.5
these, four declined oral anticoagulation therapy (three
Discharge rhythm
females and one male) and 13 were not offered (four
SR 120 83.9
females, nine first episode AF/AFL). Twelve (12) of 54
AF 21 14.7
patients (22.2%) with low-risk AF/AFL (CHA2DS2-
AFL 2 1.4
VASc 1) received oral anticoagulation therapy. Of
Discharge heart rate (beat per min) 66 (59-79)
these, nine patients received short-term oral anti-
Follow-up investigations
coagulation (dabigatran) after electrical cardioversion,
24-hr ECG Holter 7 4.9
one patient had planned elective cardioversion (dabi-
DCCV 1 0.7
gatran), one patient was on long-term anticoagulation
Echocardiogram 84 58.7
(warfarin) for a prosthetic mitral valve repair, and one
Left ventricular ejection fraction (%) 59.2 (55.4-66.1)
patient had no guideline recommended indication
Left atrium size (cm2) 21.1 (18.9-25)
(dabigatran).
Left ventricular hypertrophy 23 29.5
During the 12-month follow-up period, transthoracic
Outpatient cardiology follow-up 94 65.7
echocardiography was performed in 84 patients (58.7%)
and one underwent elective electrical cardioversion.
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Table 3. (continued). Table 4 Acute AF pathway outcomes at 12 months
(n=143).
Variablea N %
Outcomes N %
Time from AF clinic to 59.5 (46-74.8)
follow-up review, d AF-related hospitalisation (n=25) 20 14
Median (25th-75th percentile range) 1 (1-3)
Abbreviations: AF, atrial fibrillation; AFL, atrial flutter; DCCV, direct Ischaemic stroke 1 0.7
current cardioversion; ECG, electrocardiogram; SR, sinus rhythm; TOE- Systemic embolism 0 0
DCC, transoesophageal echocardiogram-direct current cardioversion; Any bleeding 8 5.6
HAS-BLED, Hypertension, Abnormal renal and liver function, Stroke, Intracranial bleeding 0 0
Bleeding, Labile INR, Elderly, Drugs or alcohol. Gastrointestinal bleeding 5 3.5
a
Categorical variables are described as frequencies (percentages) and Othera 3 2.1
continuous variables using median and 25th-75th percentile range.
b
Death 0 0
Refers to actual risk stratification scores calculated for all study subjects.
Combined outcome (stroke 1 bleeding 1 death) 9 6.3
a
Other refers to epistaxis (n=2) and frank haematuria (n=1).
However, including the 16 patients who had had an
echocardiogram performed during the 12 months pre-
patients followed by early review (generally within 24 hours)
ceding the AF clinic review (see Table 1), the overall rate
in a ward-based specialty clinic safely prevented a large
of echocardiography reaches 70% (n=100). Around two-
proportion of avoidable hospital admissions. Most patients
thirds of patients (n=94, 65.7%) were offered outpatient
(73%) spontaneously converted to sinus rhythm by short-
cardiology follow-up appointments (median time between
term follow-up at the AF clinic, with a small proportion
AF clinic and cardiology outpatient follow-up was 59.5
(12%) requiring electrical cardioversion. At 12-months
days), two of which (2.1%) did not attend.
follow-up, 20 patients were hospitalised for AF, and one
had a stroke, eight had bleeding complications and no deaths
12-Month Outcomes giving a combined 1-year adverse outcome rate of 6.3%.
None of the patients were lost to follow-up (Table 4). During Hospitalisation rates and AF-related ED visits remain high
the 12-months follow-up period, 20 patients (14%) required [2,5,7]. Previous analyses indicate that anywhere between
hospitalisation in 25 separate admissions related to AF/AFL 15–85% of ED patients with primary (i.e., no precipitating
(6 within 30 days vs 19 at between 30 days to 1 year). In cause) AF/AFL are admitted to inpatient units depending on
addition, one patient had an ischaemic stroke (a 76-year-old management approach and dispositional decisions [17–19].
female with AF and a CHA2DS2-VASc score of 7 previously The high AF-related admission rates and associated health
on warfarin developed a left middle cerebral artery ischae- care costs emphasise the need for cost-effective and safe
mic stroke 5 days after undergoing coronary artery bypass alternatives to inpatient management. As a result, several
grafting and aortic valve replacement) and eight developed ED-based interventions (observation units and specialised
bleeding complications (five gastrointestinal, two epistaxis, clinical pathways/protocols) have been implemented with
one frank haematuria). There were no deaths during follow- significant improvements noted in ED discharge and
up. The combined (stroke, bleeding, and death) 1-year admission rates, length of stay, adverse short and long-term
outcome rate was 6.3%. outcomes (e.g., stroke, deaths, and relapse of AF/AFL), and
Of the 59 patients who spontaneously reverted to sinus adherence to AF anticoagulation guidelines [10–13,19–22].
rhythm at ED discharge, four (7%) had bleeding complica- Current Australasian guidelines indicate that a rate-control
tions (two gastrointestinal, one epistaxis, one frank haema- strategy, as opposed to rhythm control, is reasonable in low
turia)—three in patients who were anticoagulated long-term. risk, haemodynamically stable patients with acute AF/AFL
There were no stroke events or other complications in this [8]. In a large Canadian study of 927 ED patients with pri-
group during the follow-up period. mary AF and no prescribed treatment protocol, the majority
of patients (85%) were discharged from ED with no reported
30-day stroke or death regardless of initial treatment
Discussion approach (i.e. rate vs. rhythm control) [18]. Our conservative
In this study of 143 patients with uncomplicated acute AF/ ‘rate-and-wait’ approach prevented hospital admission in the
AFL presenting to the ED of an academic general and tertiary greater majority of this group of patients (86%) while
care hospital, an inter-departmental evidence-based treat- maintaining low long-term AF-related hospitalisations and
ment pathway that utilises a conservative rate-control strat- complications (14% and 6.2%, respectively). This is sup-
egy and ED discharge of haemodynamically stable, low risk ported by many other studies of recent-onset AF which
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found ED discharge of haemodynamically stable patients to treatment pathways [10,11,21]. Tracking performance using
be safe in the short- and long-term regardless of the treat- specific metrics, such as patient volume trends, hospital-
ment approach or conversion to sinus rhythm [13,19–22]. In isation rates, adherence to guideline-appropriate anti-
addition, our pathway is similar to other ED-based acute AF coagulation, and adverse events is therefore crucial in
protocols [19–22] in that it coordinates the transition from ED identifying deficiencies and quality improvement efforts.
to cardiology facilitating timely access to specialist and This study has provided feedback on the AF pathway per-
ongoing/longitudinal care; over half (65.7%) of patients in formance, and stimulated discussions around developing
our study were offered outpatient cardiology follow-up ap- measures to promote the acceptance and compliance with
pointments with a median lag time of around 60 days from pathway processes and recommendations.
the AF clinic assessment.
In our cohort, 73% of the patients reverted spontaneously to Limitations
sinus rhythm within the short time-course of the AF clinic
Several limitations of our study ought to be highlighted. The
pathway. Published studies reported a high likelihood of
retrospective design and exploratory nature of our study
spontaneous restoration of sinus rhythm in patients with
inherently limits data collection of important variables of
recent-onset AF after ED presentation [11,13,21–24]. In a large
interest. We were not able to collect important information
prospective study, over two-thirds (68%) of patients with AF
on the total number of AF/AFL (primary and secondary)
of less than 72 hours’ duration spontaneously converted to
patients who presented to ED and those who were initially
sinus rhythm and shorter duration of AF (,24 hours) was the
managed under the AF pathway but did not return to the AF
only independent predictor [23]. In another study, acute AF
clinic for follow-up. It is conceivable that some patients did
terminated in 22 of 35 (63%) ED patients within 24 hours [13].
not attend their follow-up AF clinic review because of
Abadie et al. evaluated outcomes from a cohort of haemo-
logistical reasons (e.g., cost of securing transport and park-
dynamically stable AF patients without severe symptoms
ing) or resolution of AF-related symptoms, especially given
who presented to an academic tertiary care ED who were
that over two-thirds of our observed pathway patients
discharged home and reviewed in a specialty AF clinic within
spontaneously converted to sinus rhythm. In a study of a
1 to 2 working days [22]. In this study, most patients (63%)
similar pathway, only 10% of patients did not attend their
spontaneously converted to sinus rhythm within an average
clinic appointment which was scheduled within 1–2 days
2.3 days, and a greater majority at 30 days (83%). This is
after ED discharge [22].
consistent with our study where spontaneous cardioversion to
There has been recent expanded uptake of new organisa-
sinus rhythm occurred in 41% of the patients by ED discharge,
tional models of care provision in cardiology and other
and this increased to 73% in approximately 24 hours. Only a
fields, primarily driven by the COVID-19 pandemic [27,28].
minority (12%) underwent electrical cardioversion [22].
The adoption of virtual/telehealth consultations (e.g.,
Although there may be a role for flecainide in the rapid
videoconferencing) has the potential to reduce non-
conversion of recent-onset AF to sinus rhythm in selected
attendance rates and improve access to AF care especially
patients [8,25], acute pharmacological rhythm control was not
for patients with access barriers related to transport and cost
a part of our AF pathway (see Methods and Table 2). Overall,
[29]. Examining AF clinic non-attendance rates and patients’
these and results from other studies build on the accumu-
satisfaction with the in-person acute AF clinic and subse-
lating body of evidence that unnecessary electrical cardio-
quent outpatient follow-up visits are, therefore, warranted.
version can be averted in the majority of stable, low risk AF
Another limitation of our study is that hospitalisations and
patients, and that a conservative rate-and-wait strategy may
clinical outcomes during the 12-month follow-up period for
be a viable and safe alternative. This will likely result in
pathway patients who subsequently presented to other
reduced health care costs through avoiding unnecessary
hospitals that are not part of the linked online system may
hospital admissions and cardioversions.
have not been captured. Lastly, our findings are based on a
Risk stratification, as measured by the documentation of
treatment pathway implemented at a single academic ter-
stroke and bleeding risk scores, was low in our study (55%
tiary care hospital in New Zealand, and thus generalisability
and 8.4%, respectively). This could potentially be attributed
of the findings to other AF patient care settings, including
to the AF clinic being led by rotating medical registrars
rural and non-academic centres that may lack specialist
whom, although trained on the AF pathway and supervised
cardiology services, is limited.
by a cardiologist, provided AF care on a temporary basis. In
addition, the low documentation rate may reflect the usually
observed variation in compliance with clinical pathways and
guidelines [26]. Embedding the AF pathway into the hospital
Conclusion
electronic health system might facilitate pathway compliance Data from this study indicate that using a conservative ‘rate-
and drive documentation [10]. Despite our low documenta- and-wait’ strategy for acute uncomplicated AF/AFL as part
tion rates of stroke and bleeding risk, guideline-appropriate of a treatment pathway can safely prevent hospitalisations,
oral anticoagulation therapy was provided to 80% of our avoid unnecessary electrical cardioversion, and ensures the
pathway cohort, a rate that is within reported figures delivery of longitudinal AF care. Future research should
(60–91%) from previous studies utilising different AF examine other outcomes of interest including quality of life,
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2022. For personal use only. No other uses without permission. Copyright ©2022. Elsevier Inc. All rights reserved.Atrial Fibrillation Clinical Pathway 223
resource utilisation, and staff (ED and cardiology) and pa- [10] Barbic D, DeWitt C, Harris D, Stenstrom R, Grafstein E, Wu C, et al.
Implementation of an emergency department atrial fibrillation and flutter
tient satisfaction with the acute AF pathway.
pathway improves rates of appropriate anticoagulation, reduces length of
stay and thirty-day revisit rates for congestive heart failure. CJEM.
2018;20(3):392–400.
Conflicts of Interest [11] Ptaszek LM, Baugh CW, Lubitz SA, Ruskin JN, Ha G, Forsch M, et al.
Impact of a multidisciplinary treatment pathway for atrial fibrillation in
MT reports grants and speaker fees for clinical trials and the emergency department on hospital admissions and length of stay:
education from Abbott, Alere, Beckman and Roche, outside results of a multi-center study. J Am Heart Assoc. 2019;8(18):e012656.
[12] Scheuermeyer FX, Andolfatto G, Christenson J, Villa-Roel C, Rowe B.
the submitted work. The rest of authors have no conflicts of A Multicenter randomized trial to evaluate a chemical-first or electrical-
interest to declare. first cardioversion strategy for patients with uncomplicated acute atrial
fibrillation. Acad Emerg Med. 2019;26(9):969–81.
[13] Doyle B, Reeves M. “Wait and See” approach to the emergency depart-
Funding Sources ment cardioversion of acute atrial fibrillation. Emerg Med Int
2011:545023.
This research did not receive any specific grant from funding [14] Arshad M, Smyth D, Melton I, Pearson S, Troughton R. Reduced hospital-
isation and improved documentation of risk stratification – impact of a new
agencies in the public, commercial, or not-for-profit sectors. acute atrial fibrillation (AF) pathway. Heart Lung Circ. 2016;25(Suppl 1):S9.
[15] Arshad M, Smyth D, Melton I, Pearson S, Troughton R. Improvement in
risk assessment and management of anticoagulation in patients with AF
Acknowledgements in an Australasian setting: impact of a new acute af pathway. Heart Lung
Circ. 2016;25(Suppl 1):S29–30.
The authors would like to express their greatest gratitude to [16] National Ethics Advisory Committee. Ethical Guidelines for Observational
the AF Clinic staff. Part of this work has been presented at Studies: Observational Research, Audits and Related Activities. Revised edi-
tion. Wellington: Ministry of Health; 2012. Available at: https://www.
the Cardiac Society of Australia and New Zealand, New moh.govt.nz/notebook/nbbooks.nsf/0/F21C6588D45EBA67CC257A600009
Zealand Annual Scientific Meeting (Wellington, 13-15 June C6C7/$file/ethical-guidelines-for-observational-studies-2012.pdf. [accessed
2019). 27.6.21].
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Supplementary data associated with this article can be MacPhee J, et al. Thirty-day and 1-year outcomes of emergency depart-
found, in the online version, at https://doi.org/10.1016/j. ment patients with atrial fibrillation and no acute underlying medical
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