QJM vol. 98 no. 2 © Association of Physicians 2005; all rights reserved.
Correspondence |
Admissions with atrial fibrillation: disease patterns and outcomes in a District General Hospital
Sir,Atrial Fibrillation (AF) is the commonest cause of hospital admissions due to a cardiac arrhythmia. The UK had 43000 admissions with more than 350 000 bed-days used during 2001–2002.1 Its prevalence is likely to increase in an ageing population.
Many of the trials of intervention in AF are based on tertiary centre population. Few contemporary data address emergency AF admissions to UK District General Hospitals (DGHs). The Royal Surrey County Hospital is a typical DGH (180 medical beds, A&E, MAU). A registry was implemented to measure AF-related admissions and elucidate clinical practices in their management.
The registry was maintained for all emergency admissions with AF, August 2001 to September 2002. AF was typed by the standard 3P classification as ‘paroxysmal’, ‘persistent’ or ‘permanent’ by a cardiologist.2
We recorded 173 consecutive cases (mean age 71.6 years, male 67%; national average, 69 years and male 66%). In most (58%), AF onset was definitely >48 h, and was indeterminate in 16%, only 26% presenting within 48 h. Outcomes are illustrated in Table 1. Approximately 7% spontaneously converted to sinus rhythm within 12 h of admission and 12% had immediate chemical or Direct Current Cardioversion (DCCV). The majority were initiated on rate control medication pending a decision regarding DCCV.
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Some 46% had AF as a primary cause for their admission; other causes included cardiac events (25%), respiratory illness (8%), stroke (7%), sepsis (2%) and miscellaneous associations (12%). The different types of AF did not exhibit significant seasonal variation.
Long-term anticoagulation therapy had previously been established in 24%; a further 34% were started on warfarin during the hospital admission, with aspirin alone used in 37%. No significant age differences were noted between the aspirin and warfarin groups. Combinations were used in 6% and neither in 11%.
Most patients (85%) with persistent AF need to be assessed for rhythm control but 11% could have immediate conversion to sinus rhythm. A small number (about 5%) however, will spontaneously convert. About half of those with paroxysmal AF will simply need adjustment of their antidysrhythmic therapy. Approximately 20% spontaneously convert and 30% go onto chemical or electrical cardioversion. Permanent AF can be promptly identified in 28% of all admissions. This number theoretically should increase after the addition of cases of persistent AF who later fail assessment for rhythm control.
Only 26% of admissions presented within 48 h of onset. This is important, as such patients can be offered immediate chemical or electrical cardioversion, without undue concerns regarding clot formation and consequent embolic phenomena.3,4 Patient education and improvement in GP referral systems could increase this number via early expert assessment, and thus allow prompt conversion to sinus rhythm, thereby reducing length of stay and out-patient DCCV lists.
Transoesophageal echocardiography-guided DCCV is suitable for those patients with AF of onset >48 h, or unknown, who qualify for rhythm control. It shortens hospital stay and enables prompt DCCV without the initial anticoagulation phase. A significant subgroup (28%) can be potentially identified for this promising management strategy.
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Department of Cardiology Royal Surrey County Hospital Guildford e-mail: rito.mitra{at}gmail.com
References
1. UK Hospital Episode Statistics 1998–2002. Department of Health, 2003. [http://www.doh.gov.uk/hes/free_data/index.html]
2. Gallagher MM, Camm J. Classification of atrial fibrillation. Am J Cardiol 1998; 82(8A):18–28N.[CrossRef]
3. Levy S, Breithardt G, Campbell RW, et al. Atrial fibrillation: current knowledge and recommendations for management. Working Group on Arrhythmias of the European Society of Cardiology. Eur Heart J 1998; 19:1294–320.
4. Fuster V, Ryden LE, Asinger RW, et al. ACC/AHA/ESC Guidelines for the Management of Patients With Atrial Fibrillation: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the North American Society of Pacing and Electrophysiology. Circulation 2001; 104:2118–50.
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