Emergency department management of atrial fibrillation: 2023 consensus from the Spanish Society of Emergency Medicine (SEMES), the Spanish Society of Cardiology (SEC), and the Spanish Society of Thrombosis and Hemostasis (SETH). / Manejo de la fibrilación auricular en los servicios de urgencias hospitalarios: actualización a 2023 del consenso de la Sociedad Española de Medicina de Urgencias (SEMES), la Sociedad Española de Cardiología (SEC) y la Sociedad Española de Trombosis y Hemostasia (SETH).

OBJECTIVES: Atrial fibrillation (AF) is the most prevalent sustained arrhythmia managed in emergency departments, and the already high prevalence of this arrhythmia is increasing in Spain. This serious condition associated with increased mortality and morbidity has a negative impact on patient quality of life and the functioning of the health care system. The management of AF requires consideration of diverse clinical variables and a large number of possible therapeutic approaches, justifying action plans to coordinate the work of several medical specialties in the interest of providing appropriate care and optimizing resources. This consensus statement brings together recommendations for emergency department management of AF based on available evidence adapted to special circumstances. The statement was drafted by a multidisciplinary team of specialists from the Spanish Society of Emergency Medicine (SEMES), the Spanish Society of Cardiology (SEC), and the Spanish Society of Thrombosis and Hemostasis (SETH). Strategies for stroke prophylaxis, measures to bring heart rate and heart rhythm under control, and related diagnostic and logistic issues are discussed in detail.

OBJETIVO: La fibrilación auricular (FA) es la arritmia sostenida de mayor prevalencia en los servicios de urgencias (SU), y en España presenta una frecuentación elevada y creciente. Esta arritmia es una enfermedad grave, que incrementa la mortalidad y asocia una relevante morbilidad e impacto en la calidad de vida de los pacientes y en el funcionamiento de los servicios sanitarios. La diversidad de aspectos clínicos a considerar y el elevado número de opciones terapéuticas posibles justifican la implementación de estrategias de actuación coordinadas entre los diversos profesionales implicados, con el fin de incrementar la adecuación del tratamiento y optimizar el uso de recursos. Este documento, realizado por un grupo multidisciplinario de expertos en arritmias cardiacas miembros de la Sociedad Española de Medicina de Urgencias y Emergencias, la Sociedad Española de Cardiología y la Sociedad Española de Trombosis y Hemostasia, recoge las recomendaciones para el manejo de la FA en los SU hospitalarios, basadas en la evidencia disponible y adaptadas a las especiales circunstancias de los mismos. En él se analizan con detalle las estrategias de profilaxis tromboembólica, control de frecuencia y control del ritmo, y los aspectos logísticos y diagnósticos relacionados.

Sex-related differences in benefits of anticoagulation therapy in elderly patients with atrial fibrillation: a subanalysis of the EMERG-AF study. / Diferencias de sexo en los beneficios de la anticoagulación en pacientes ancianos con fibrilación auricular: un subanálisis del estudio EMERG-AF.

OBJECTIVES: To analyze the long-term benefits and safety of oral anticoagulation therapy prescribed in emergency departments for elderly patients with atrial fibrillation, and to detect any sex-related differences present. MATERIAL AND METHODS: Post-hoc analysis of data compiled by the EMERG-AF group (Spanish acronym for Emergency Department Stroke Prophylaxis and Guidelines Implementation in Atrial Fibrillation). Consecutive patients aged 75 years or older with atrial fibrillation who were treated in 62 EDs were included. We recorded clinical data and anticoagulants prescribed. Patients were followed for 1 year. The main outcome variable was a composite of death, thromboembolism, or major bleeding within 1 year. RESULTS: Data for 690 patients were registered; 386 (55.9%) were women. At discharge, 575 patients (83.3%) were on anticoagulants; therapy was started in the ED for 96 of them. A total of 158 patients (22.9%) had experienced at least 1 component of the main outcome within 1 year: 118 (17.1%) died, 22 (2.7%) had thromboembolic complications, and 34 (4.9%) had major bleeding. After adjustment for main clinical characteristics, hazard ratios (HRs) showed that anticoagulation therapy was associated with a reduction in the composite outcome (HR, 0.372; 95% CI, 0.236-0.587; P .001) but not specifically with major bleeding overall. When data for women were analyzed separately, anticoagulant therapy was again associated with a reduction in the composite outcome (HR, 0.372; 95% CI, 0.236-0.587; P .001) and also with death (HR, 0.281; 95% CI, 0.168-0.469; P .001), even in patients with anticoagulant prescriptions initiated on discharge from the ED. These associations did not reach statistical significance in men. CONCLUSION: ED anticoagulant prescription for elderly patients with atrial fibrillation is safe and contributes to a reduction in mortality. Women in this age group benefited more than men from starting anticoagulation during the acute phase in the ED.

OBJETIVO: Analizar los beneficios y seguridad a largo plazo de la anticoagulación oral (ACO) prescrita en los servicios de urgencias (SU) a pacientes mayores con fibrilación auricular (FA) y las diferencias en función del sexo. METODO: Se trata de un análisis post-hoc del estudio EMERG-AF. Se incluyeron pacientes consecutivos $ 75 años, que consultaron en 62 SU por FA. Se recogieron datos clínicos y ACO. La variable principal estuvo compuesta por muerte, tromboembolia o sangrado mayor en 1 año. RESULTADOS: Se incluyeron 690 pacientes, 386 mujeres (55,9%). Al alta, 575 pacientes (83,3%) estaban con ACO. En 96 de ellos se inició en el SU. Tras 1 año, la variable principal sucedió en 158 pacientes (22,9%): 118 (17,1%) fallecieron, 22 (2,7%) tuvieron una complicación tromboembólica y 34 (4,9%) una hemorragia mayor. Tras ajustar por las principales características clínicas, la ACO se asoció a una reducción en la variable principal (HR: 0,372, IC 95%: 0,236-0,587, p 0,001), pero no se asoció con la hemorragia mayor. En las mujeres, la ACO se asoció con una reducción en la variable principal (HR: 0,372, IC 95%: 0,236-0,587, p 0,001) y una menor mortalidad (HR: 0,281, IC 95%: 0,168-0,469, p 0,001), incluidos pacientes con nueva prescripción y en aquellos dados de alta. Esta asociación no alcanzó significación en los hombres. CONCLUSIONES: La prescripción de ACO en los SU a pacientes mayores con FA es segura y contribuye a reducir la mortalidad. En este grupo etario, las mujeres se benefician más que los hombres de iniciar la ACO en la fase aguda.

Long-term prognosis and emergency management for patients with an implantable cardioverter defibrillator: the EMERGE-ICD study. / Estudio EMERG-ICD: manejo y pronóstico a largo plazo de las urgencias en los pacientes portadores de un desfibrilador automático implantable.

OBJECTIVES: Patients with implantable cardioverter defibrillators (ICDs) are at risk of serious complications that are often treated in hospital emergency departments (EDs). The EMERG-ICD study (Emergency Department Management and Long-term Prognosis for Patients with ICDs) analysed management and long-term prognosis of ED patients with an ICD after an acute clinical event. MATERIAL AND METHODS: Observational multicenter cohort study including consecutive adult patients with ICDs who came to 27 hospital EDs in Spain for treatment and were followed for 10 years. We collected clinical variables on presentation, ED case management variables, and the date and cause of death in each case. The primary outcome variable was all-cause mortality. RESULTS: Five-hundred three patients were studied; 471 had structural heart disease (SHD) and 32 had primary electrical heart disease (PEHD). Beta-blockers were prescribed in the ED for 55% of the patients for whom they were indicated. Twenty-four (4.8%), 75 (15.7%), and 368 (73.2%) patients died during follow-up at 1 month, 1 year, and 10 years, respectively. Of these, 363 (77.1%) had SHD and 5 (15.6%) had PEHD (hazard ratio, 8.05 (95% CI, 3.33- 19.46). Among patients with SHD, the cause of death was cardiovascular in 66%. Mortality correlated significantly with seeking care for cardiovascular symptoms, advanced age, male sex, diabetes, a New York Heart Association score of 2 or more, severe ventricular dysfunction, and long-term amiodarone therapy. CONCLUSION: Prognosis after an acute clinical event is poor in patients with SHD and ICDs, mainly due to cardiovascular causes, especially among patients with associated comorbidities and cardiovascular complaints. Mortality is lower in patients with PEHD.

OBJETIVO: Los pacientes portadores de desfibriladores automáticos implantables (DAI) tienen riesgo de complicaciones graves que son atendidas con frecuencia en los servicios de urgencias hospitalarios (SUH). Este estudio analiza el manejo y el pronóstico de las urgencias en portadores de un DAI. METODO: Estudio de cohorte observacional y multicéntrico que incluyó de manera consecutiva pacientes adultos portadores de DAI que consultaron en 27 SUH en España, con seguimiento posterior a 10 años. Se recogieron las variables clínicas, manejo en el SUH, fecha y causa del fallecimiento. La variable de resultado primaria fue la mortalidad por cualquier causa. RESULTADOS: Se incluyeron 503 pacientes, 471 con cardiopatía estructural (CE) y 32 con enfermedad eléctrica primaria cardiaca (EEPC). Se prescribió betabloqueantes en el SUH al 55% de los pacientes con indicación. Durante el seguimiento fallecieron 24 (4,8%), 75 (15,7%) y 368 pacientes (73,2%) a 1 mes, 1 año y 10 años, respectivamente. De estos, 363 tenían CE y 5 EEPC (77,1% vs 15,6%, HR 8,05 IC 95% 3,33-19,46). Entre los pacientes con CE, la mortalidad global fue de causa cardiovascular en el 66% de los casos. La mortalidad se asoció significativamente con la consulta por una causa cardiovascular, edad avanzada, sexo masculino, diabetes, NHYA 2, disfunción ventricular grave y tratamiento crónico con amiodarona. CONCLUSIONES: El pronóstico de los portadores de DAI con CE es muy adverso, fundamentalmente debido a complicaciones cardiovasculares en pacientes con comorbilidades que consultan por sintomatología cardiovascular. La mortalidad es menor en los pacientes con EEPC.

First confirmation of importation and transmission in Spain of the newly identified SARS-CoV-2 B.1.1.7 variant.

INTRODUCTION: A newly identified SARS-CoV-2 variant, VOC202012/01 originating lineage B.1.1.7, recently emerged in the United Kingdom. The rapid spread in the UK of this new variant has caused other countries to be vigilant. MATERIAL AND METHODS: We based our initial screening of B.1.1.7 on the dropout of the S gene signal in the TaqPath assay, caused by the 69/70 deletion. Subsequently, we confirmed the B.1.1.7 candidates by whole genome sequencing. RESULTS: We describe the first three imported cases of this variant from London to Madrid, subsequent post-arrival household transmission to three relatives, and the two first cases without epidemiological links to UK. One case required hospitalization. In all cases, drop-out of gene S was correctly associated to the B.1.1.7 variant, as all the corresponding sequences carried the 17 lineage-marker mutations. CONCLUSION: The first identifications of the SARS-CoV-2 B.1.1.7 variant in Spain indicate the role of independent introductions from the UK coexisting with post-arrival transmission in the community, since the early steps of this new variant in our country.

Emergency department prescription of sinus rhythm maintenance therapy for patients treated for atrial fibrillation: a secondary analysis of the HERMES-AF study / Análisis del tratamiento para mantener el ritmo sinusal en pacientes con fibrilación auricular prescrito en los servicios de urgencias: subanálisis del estudio HERMES-AF

OBJECTIVES: The maintenance of sinus rhythm by means of antiarrhythmic drugs and/or upstream therapy to counter cardiac remodeling is fundamental to the management of atrial fibrillation (AF). This study aimed to analyze this approach and its appropriateness in the setting of hospital emergency departments. MATERIAL AND METHODS: Secondary analysis of data from the multicenter observational cross-sectional HERMES-AF study carried out in 124 hospitals representative of the Spanish national health service in 2011. Included were consecutive patients with AF restored to sinus rhythm who were discharged home from emergency care. RESULTS: A total of 449 patients were included; 204 (45.4%) were already on sinus rhythm maintenance therapy. Of ,the 245 remaining patients, 107 (43.67%) were prescribed maintenance treatment in the emergency department, as follows: 41, an antiarrhythmic drug; 19, upstream therapy; and 49, both treatments. The selection of an antiarrhythmic drug did not follow guideline recommendations in 10 patients (11.8%). Antiarrhythmic drug prescription was associated with having had a prior episode of AF (odds ratio [OR], 2.024; 95% CI, 1.196-3.424; P = .009); a heart rate of more than 110 beats/min (OR, 2.147; 95% CI, 1.034-4.456, P = 0.40); and prescription of anticoagulation on discharge (OR, 1.862; 95% CI, 1.094-3.170; P = .022). Upstream therapy prescription was associated only with a heart rate over 110 beats/min (OR, 2.187; 95% CI, 1.005-4.757; P = .018). In total, 311 patients (69.23%) were discharged from the emergency department with sinus rhythm maintenance therapy: 87 with an antiarrhythmic drug, 117 with an upstream therapy, and 107 with both. CONCLUSION: Treatment to prevent the recurrence of AF is underprescribed in emergency departments. Increasing such prescription and ensuring the appropriateness of antiarrhythmic therapy prescribed are points emergency departments can improve in the interest of better sinus rhythm maintenance.

OBJETIVO: El mantenimiento del ritmo sinusal (RS) con fármacos antiarrítmicos (FAA) y/o tratamiento del remodelado (TRM) es parte fundamental en la estrategia de control del ritmo en la fibrilación auricular (FA). Este estudio analiza estas estrategias y su adecuación en los servicios de urgencias hospitalarios (SUH). METODO: Análisis secundario del estudio multicéntrico observacional transversal HERMES-AF, desarrollado en 124 SUH representativos del sistema sanitario español en 2011. Se incluyeron pacientes consecutivos con FA que revirtieron a RS y fueron dados de alta desde urgencias. RESULTADOS: Se incluyeron 449 pacientes: 204 (45,4%) ya realizaban tratamiento para mantenimiento del RS. De los 245 restantes se prescribió tratamiento en el SUH a 107 (43,7%): 41 con FAA, 19 TRM y en 47 ambas terapias. En 10 casos (11,8%) la selección del FAA no era acorde a las recomendaciones de las guías. La prescripción de FAA se asoció a FA previa [odds ratio (OR) 2,024, IC 95%: 1,196-3,424, p = 0,009], frecuencia cardiaca > 110 lpm (OR 2,147, IC 95%: 1,034-4,456, p = 0,040) y anticoagulación al alta (OR 1,862, IC 95%: 1,094-3,170, p = 0,022). El TRM se asoció a frecuencia cardiaca > 110 lpm (OR 2,187, IC 95%: 1,005-4,757, p = 0,018). En total, al alta del SUH 311 pacientes (69,2%) recibían tratamiento para mantenimiento del RS (87 con FAA, 117 con TRM y 107 con ambas terapias). CONCLUSIONES: La prescripción de tratamiento para evitar las recurrencias de la FA es insuficiente en los SUH. Extender esta prescripción y mejorar la adecuación del tratamiento antiarrítmico son áreas de mejora de la estrategia de control del ritmo en los SUH.

Factors associated with poor prognosis in patients with atrial fibrillation: An emergency department perspective the EMERG-AF study.

OBJECTIVE: We sought to identify the factors associated with a worse prognosis in Emergency Department (ED) patients with atrial fibrillation (AF), crucial information to guide management decisions. METHODS: This is a secondary analysis of a prospective, multicenter, observational cohort of consecutive AF patients attended in 62 EDs in Spain. Clinical variables were collected on enrollment. Follow-up was performed at 30 days and one year. The primary composite outcome was all-cause mortality, major bleeding and/or stroke at one year. Secondary outcomes were each of these components considered separately, plus one-year cardiovascular mortality and the composite outcome at 30 days. RESULTS: We analyzed 1107 patients. The primary outcome occurred in 209 patients (18.9%), one-year all-cause mortality in 151 (13.6%), major bleeding in 47 (4.2%), and stroke in 31 (2.8%). Disability (HR 2.064, 95% CI 1.478-2.882), previous known AF (HR 1.829, 95% CI 1.096-3.051), long duration of the AF episode (HR 1.849, 95% CI 1.052-3.252) and renal failure (HR 2.073, 95% CI 1.433-2.999) were independently associated with the primary outcome, whereas anticoagulation at discharge was inversely associated (HR 0.576, 95% CI 0.415-0.801). Disability was associated with mortality, cardiovascular mortality, and the composite at 30 days, and renal failure with mortality and major bleeding. CONCLUSIONS: Comorbidities like renal failure, long AF duration and disability were related to adverse outcomes and should be decisive to guide management decisions in ED patients with AF. Anticoagulation had a positive impact on prognosis and should be the mainstay of therapy in AF patients attended in ED.

Headache History-Taking in an Emergency Department: Impact Evaluation of a Training Session.

INTRODUCTION: Headache represents about 25% of the total neurological consultations at the emergency department (ED). Up to 80% of these consultations are represented by primary headaches, in which an accurate and directed history-taking may help reach the specific diagnosis avoiding unnecessary complementary tests and reducing diagnostic latencies. METHODS: We carried out a training session on headache management at the ED, focusing on history-taking and primary headaches' diagnoses and management. We retrospectively compared the number of variables included in the medical reports and the percentage of patients who were diagnosed and/or treated for a primary headache between two months before and two months after the training session. RESULTS: A total of 369 medical histories were analyzed for this study (196 before and 173 after the training session). The number of essential variables regarding pain characteristics included in the medical reports showed a post-intervention increment from 4.34 ± 1.224 to 4.67 ± 1.079 (P = .007) and the number of total items registered also increased from 6.87 ± 1.982 to 7.53 ± 1.686 (P = 0.001). The percentage of patients that were given a specific diagnosis for primary headache showed an increment of 11.8% (P = .002) in the post-intervention group. CONCLUSION: Educational interventions can improve history-taking in headache patients in the ED. This fact grants them as potential efficient measures to optimize patient management at Emergency Room.

First confirmation of importation and transmission in Spain of the newly identified SARS-CoV-2 B.1.1.7 variant.

INTRODUCTION: A newly identified SARS-CoV-2 variant, VOC202012/01 originating lineage B.1.1.7, recently emerged in the United Kingdom. The rapid spread in the UK of this new variant has caused other countries to be vigilant. MATERIAL AND METHODS: We based our initial screening of B.1.1.7 on the dropout of the S gene signal in the TaqPath assay, caused by the 69/70 deletion. Subsequently, we confirmed the B.1.1.7 candidates by whole genome sequencing. RESULTS: We describe the first three imported cases of this variant from London to Madrid, subsequent post-arrival household transmission to three relatives, and the two first cases without epidemiological links to UK. One case required hospitalization. In all cases, drop-out of gene S was correctly associated to the B.1.1.7 variant, as all the corresponding sequences carried the 17 lineage-marker mutations. CONCLUSION: The first identifications of the SARS-CoV-2 B.1.1.7 variant in Spain indicate the role of independent introductions from the UK coexisting with post-arrival transmission in the community, since the early steps of this new variant in our country.

Association between acute heart failure and major cardiovascular events in atrial fibrillation patients presenting at the emergency department: an EMERG-AF ancillary study.

BACKGROUND: There is little evidence concerning the impact of acute heart failure (AHF) on the prognosis of atrial fibrillation patients attending the emergency department (ED). OBJECTIVE: To know the influence of AHF on adverse long-term outcomes in patients presenting with atrial fibrillation in ED. DESIGN, SETTING AND PARTICIPANTS: Secondary analysis of a prospective, multicenter, observational cohort of consecutive atrial fibrillation patients, performed in 62 Spanish EDs. EXPOSURE: Patients presenting with atrial fibrillation in ED were divided by the presence or absence of AHF at arrival. OUTCOME MEASURES AND ANALYSIS: Primary outcome: combination of 1-year all-cause mortality, major bleeding, stroke and other major cardiovascular events (MACE). Secondary outcomes: each of these events analyzed separately. Cox and logistic regression were used to investigate adjusted significant associations between AHF and outcomes. MAIN RESULTS: Totally, 1107 consecutive ED patients with atrial fibrillation attending ED were analyzed, 262 (23.7%) with AHF. The primary outcome occurred in 433 patients (39.1%), 1-year all-cause mortality in 151 patients (13.6%), major bleeding in 47 patients (4.2 %), stroke in 31 patients (2.8 %) and other MACE in 333 patients (30.1%). AHF was independently related to the primary outcome [odds ratio (OR), 1.422; 95% confidence interval (CI), 1.020-1.981; P = 0.037)] and 1-year MACE (OR, 1.797; 95% CI, 1.285-2.512; P = 0.001), but not to 1-year all-cause mortality, stroke or bleeding. CONCLUSIONS: The coexistence of AHF in patients presenting with atrial fibrillation in ED is associated to a worse 1-year outcome mainly due to MACE, but does not impact in overall mortality.

IL-6 serum levels predict severity and response to tocilizumab in COVID-19: An observational study.

BACKGROUND: Patients with coronavirus disaese 2019 (COVID-19) can develop a cytokine release syndrome that eventually leads to acute respiratory distress syndrome requiring invasive mechanical ventilation (IMV). Because IL-6 is a relevant cytokine in acute respiratory distress syndrome, the blockade of its receptor with tocilizumab (TCZ) could reduce mortality and/or morbidity in severe COVID-19. OBJECTIVE: We sought to determine whether baseline IL-6 serum levels can predict the need for IMV and the response to TCZ. METHODS: A retrospective observational study was performed in hospitalized patients diagnosed with COVID-19. Clinical information and laboratory findings, including IL-6 levels, were collected approximately 3 and 9 days after admission to be matched with preadministration and postadministration of TCZ. Multivariable logistic and linear regressions and survival analysis were performed depending on outcomes: need for IMV, evolution of arterial oxygen tension/fraction of inspired oxygen ratio, or mortality. RESULTS: One hundred forty-six patients were studied, predominantly males (66%); median age was 63 years. Forty-four patients (30%) required IMV, and 58 patients (40%) received treatment with TCZ. IL-6 levels greater than 30 pg/mL was the best predictor for IMV (odds ratio, 7.1; P < .001). Early administration of TCZ was associated with improvement in oxygenation (arterial oxygen tension/fraction of inspired oxygen ratio) in patients with high IL-6 (P = .048). Patients with high IL-6 not treated with TCZ showed high mortality (hazard ratio, 4.6; P = .003), as well as those with low IL-6 treated with TCZ (hazard ratio, 3.6; P = .016). No relevant serious adverse events were observed in TCZ-treated patients. CONCLUSIONS: Baseline IL-6 greater than 30 pg/mL predicts IMV requirement in patients with COVID-19 and contributes to establish an adequate indication for TCZ administration.

Analysis of clinical characteristics and outcomes in patients with COVID-19 based on a series of 1000 patients treated in Spanish emergency departments. / Evaluación de las características clínicas y evolución de pacientes con COVID-19 a partir de una serie de 1000 pacientes atendidos en servicios de urgencias españoles.

OBJECTIVES: To describe the clinical characteristics of patients with coronavirus disease 2019 (COVID-19) treated in hospital emergency departments (EDs) in Spain, and to assess associations between characteristics and outcomes. MATERIAL AND METHODS: Prospective, multicenter, nested-cohort study. Sixty-one EDs included a random sample of all patients diagnosed with COVID-19 between March 1 and April 30, 2020. Demographic and baseline health information, including concomitant conditions; clinical characteristics related to the ED visit and complementary test results; and treatments were recorded throughout the episode in the ED. We calculated crude and adjusted odds ratios for risk of in-hospital death and a composite outcome consisting of the following events: intensive care unit admission, orotracheal intubation or mechanical ventilation, or in-hospital death. The logistic regression models were constructed with 3 groups of independent variables: the demographic and baseline health characteristics, clinical characteristics and complementary test results related to the ED episode, and treatments. RESULTS: The mean (SD) age of patients was 62 (18) years. Most had high- or low-grade fever, dry cough, dyspnea, and diarrhea. The most common concomitant conditions were cardiovascular diseases, followed by respiratory diseases and cancer. Baseline patient characteristics that showed a direct and independent association with worse outcome (death and the composite outcome) were age and obesity. Clinical variables directly associated with worse outcomes were impaired consciousness and pulmonary crackles; headache was inversely associated with worse outcomes. Complementary test findings that were directly associated with outcomes were bilateral lung infiltrates, lymphopenia, a high platelet count, a D-dimer concentration over 500 mg/dL, and a lactate-dehydrogenase concentration over 250 IU/L in blood. CONCLUSION: This profile of the clinical characteristics and comorbidity of patients with COVID-19 treated in EDs helps us predict outcomes and identify cases at risk of exacerbation. The information can facilitate preventive measures and improve outcomes.

OBJETIVO: Describir las características clínicas de los pacientes con COVID-19 atendidos en los servicios de urgencias hospitalarios (SUH) españoles y evaluar su asociación con los resultados de su evolución. METODO: Estudio multicéntrico, anidado en una cohorte prospectiva. Participaron 61 SUH que incluyeron pacientes seleccionados aleatoriamente de todos los diagnosticados de COVID-19 entre el 1 de marzo y el 30 de abril de 2020. Se recogieron características basales, clínicas, de exploraciones complementarias y terapéuticas del episodio en los SUH. Se calcularon las odds ratio (OR) asociadas a la mortalidad intrahospitalaria y al evento combinado formado por el ingreso en unidad de cuidados intensivos (UCI), la intubación orotraqueal o ventilación mecánica invasiva (IOT/ VMI), crudas y ajustadas con modelos de regresión logística para tres grupos de variables independientes: basales, clínicas y de exploraciones complementarias. RESULTADOS: La edad media fue de 62 años (DE 18). La mayoría manifestaron fiebre, tos seca, disnea, febrícula y diarrea. Las comorbilidades más frecuentes fueron las enfermedades cardiovasculares, seguidas de las respiratorias y el cáncer. Las variables basales que se asociaron independientemente y de forma directa a peores resultados evolutivos (tanto a mortalidad como a evento combinado) fueron edad y obesidad; las variables clínicas fueron disminución de consciencia y crepitantes a la auscultación pulmonar, y de forma inversa cefalea; y las variables de resultados de exploraciones complementarias fueron infiltrados pulmonares bilaterales y cardiomegalia radiológicos, y linfopenia, hiperplaquetosis, dímero-D > 500 mg/dL y lactato-deshidrogenasa > 250 UI/L en la analítica. CONCLUSIONES: Conocer las características clínicas y la comorbilidad de los pacientes con COVID-19 atendidos en urgencias permite identificar precozmente a la población más susceptible de empeorar, para prever y mejorar los resultados.

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.

Benefits of Emergency Departments' Contribution to Stroke Prophylaxis in Atrial Fibrillation: The EMERG-AF Study (Emergency Department Stroke Prophylaxis and Guidelines Implementation in Atrial Fibrillation).

BACKGROUND AND PURPOSE: Long-term benefits of initiating stroke prophylaxis in the emergency department (ED) are unknown. We analyzed the long-term safety and benefits of ED prescription of anticoagulation in atrial fibrillation patients. METHODS: Prospective, multicenter, observational cohort of consecutive atrial fibrillation patients was performed in 62 Spanish EDs. Clinical variables and thromboprophylaxis prescribed at discharge were collected at inclusion. Follow-up at 1 year post-discharge included data about thromboprophylaxis and its complications, major bleeding, and death; risk was assessed with univariate and bivariate logistic regression models. RESULTS: We enrolled 1162 patients, 1024 (88.1%) at high risk according to CHA2DS2-VASc score. At ED discharge, 935 patients (80.5%) were receiving anticoagulant therapy, de novo in 237 patients (55.2% of 429 not previously treated). At 1 year, 48 (4.1%) patients presented major bleeding events, and 151 (12.9%) had died. Anticoagulation first prescribed in the ED was not related to major bleeding (hazard ratio, 0.976; 95% confidence interval, 0.294-3.236) and was associated with a decrease in mortality (hazard ratio, 0.398; 95% confidence interval, 0.231-0.686). Adjusting by the main clinical and sociodemographic characteristics, concomitant antiplatelet treatment, or destination (discharge or admission) did not affect the results. CONCLUSIONS: Prescription of anticoagulation in the ED does not increase bleeding risk in atrial fibrillation patients at high risk of stroke and contributes to decreased mortality.

Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study.

AIMS: Intravenous procainamide and amiodarone are drugs of choice for well-tolerated ventricular tachycardia. However, the choice between them, even according to Guidelines, is unclear. We performed a multicentre randomized open-labelled study to determine the safety and efficacy of intravenous procainamide and amiodarone for the acute treatment of tolerated wide QRS complex (probably ventricular) tachycardia. METHODS AND RESULTS: Patients were randomly assigned to receive intravenous procainamide (10 mg/kg/20 min) or amiodarone (5 mg/kg/20 min). The primary endpoint was the incidence of major predefined cardiac adverse events within 40 min after infusion initiation. Of 74 patients included, 62 could be analysed. The primary endpoint occurred in 3 of 33 (9%) procainamide and 12 of 29 (41%) amiodarone patients (odd ratio, OR = 0.1; 95% confidence interval, CI 0.03-0.6; P = 0.006). Tachycardia terminated within 40 min in 22 (67%) procainamide and 11 (38%) amiodarone patients (OR = 3.3; 95% CI 1.2-9.3; P = 0.026). In the following 24 h, adverse events occurred in 18% procainamide and 31% amiodarone patients (OR: 0.49; 95% CI: 0.15-1.61; P: 0.24). Among 49 patients with structural heart disease, the primary endpoint was less common in procainamide patients (3 [11%] vs. 10 [43%]; OR: 0.17; 95% CI: 0.04-0.73, P = 0.017). CONCLUSIONS: This study compares for the first time in a randomized design intravenous procainamide and amiodarone for the treatment of the acute episode of sustained monomorphic well-tolerated (probably) ventricular tachycardia. Procainamide therapy was associated with less major cardiac adverse events and a higher proportion of tachycardia termination within 40 min.

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.

Prognostic value of the electrocardiogram in patients with syncope: data from the group for syncope study in the emergency room (GESINUR).

BACKGROUND: The Group for Syncope Study in the Emergency Room (GESINUR) was a Spanish multicenter, prospective, observational study that evaluated the clinical presentation and acute management of loss of consciousness in Spain. Several studies have shown that an abnormal ECG is a poor prognostic factor in patients with syncope. However, the prognostic significance of each ECG abnormality is not well known. OBJECTIVE: The purpose of this study was to study the association between specific ECG abnormalities and mortality in patients with syncope from the GESINUR study. METHODS: All patients in the GESINUR study who had syncope and had available, readable ECG and 12-month follow-up data were included in this retrospective observational study (n = 524, age 57 ± 22 years, 50.6% male). ECG abnormalities were analyzed and assessed to evaluate whether an association with all-cause mortality existed at 12 months. RESULTS: ECGs were classified as abnormal in 344 patients (65.6%). Thirty-three patients died during follow-up (6.3%), but only 1 due to sudden cardiovascular death. Atrial fibrillation (odds ratio [OR] 6.8, 95% confidence interval [CI] 2.8-16.3, P <.001), intraventricular conduction disturbances (OR 3.8, 95% CI 1.7-8.3, P = .001), left ventricular hypertrophy ECG criteria (OR 6.3, 95% CI 1.5-26.3, P = .011), and ventricular pacing (OR 21.8, 95% CI 4.1-115.3, P <.001) were the only independent ECG predictors of all-cause mortality. CONCLUSION: Although an abnormal ECG in patients with syncope is a common finding, only the presence of atrial fibrillation, intraventricular conduction disturbances, left ventricular hypertrophy ECG criteria, and ventricular pacing is associated with 1-year all-cause mortality.

Epidemiological characteristics and diagnostic approach in patients admitted to the emergency room for transient loss of consciousness: Group for Syncope Study in the Emergency Room (GESINUR) study.

AIMS: To assess the clinical presentation and acute management of patients with transient loss of consciousness (T-LOC) in the emergency department (ED). METHODS AND RESULTS: A multi-centre prospective observational study was carried out in 19 Spanish hospitals over 1 month. The patients included were > or =14 years old and were admitted to the ED because of an episode of T-LOC. Questionnaires and corresponding electrocardiograms (ECGs) were reviewed by a Steering Committee (SC) to unify diagnostic criteria, evaluate adherence to guidelines, and diagnose correctly the ECGs. We included 1419 patients (prevalence, 1.14%). ECG was performed in 1335 patients (94%) in the ED: 498 (37.3%) ECGs were classified as abnormal. The positive diagnostic yield ranged from 0% for the chest X-ray to 12% for the orthostatic test. In the ED, 1217 (86%) patients received a final diagnosis of syncope, whereas the remaining 202 (14%) were diagnosed of non-syncopal transient loss of consciousness (NST-LOC). After final review by the SC, 1080 patients (76%) were diagnosed of syncope, whereas 339 (24%) were diagnosed of NST-LOC (P < 0.001). Syncope was diagnosed correctly in 84% of patients. Only 25% of patients with T-LOC were admitted to hospitals. CONCLUSION: Adherence to clinical guidelines for syncope management was low; many diagnostic tests were performed with low diagnostic yield. Important differences were observed between syncope diagnoses at the ED and by SC decision.

Analysis of current management of atrial fibrillation in the acute setting: GEFAUR-1 study.

STUDY OBJECTIVE: Limited information relative to the management of atrial fibrillation in the emergency department (ED) daily practice is available. This study evaluates current management of atrial fibrillation in this setting to identify areas for practice improvement. METHODS: This was a prospective multicenter observational study carried out in 12 EDs. Adults in whom atrial fibrillation was demonstrated in an ECG obtained in the ED were included. Clinical variables and atrial fibrillation management in the ED were prospectively collected by the treating physicians using a standardized questionnaire. Patients with rapid ventricular response (>100 beats/min) were considered eligible for rate control, and patients with recent-onset episodes (<48 hours) were eligible for rhythm control. RESULTS: Of 1,178 patients, 41% presented with a rapid ventricular response and 21% had recent-onset episodes. Rhythm control was attempted in 42% of eligible patients, with antiarrhythmic drugs in 88% of cases (I-C drugs in 44% of patients; amiodarone in 43% of patients). Overall effectiveness of pharmacologic cardioversion was 63% (amiodarone 54.5%, flecainide 93%), whereas electrocardioversion was effective in 87.5% of cases. Rate control was performed in 68.3% of eligible patients (overall effectiveness 47.8%); digoxin was used in 67% of cases (effectiveness 45%). Both strategies were selected in 4.5% of cases, whereas no treatment for atrial fibrillation was performed in 60% of patients. CONCLUSION: In our ED population, rate-control effectiveness is poor and rhythm control is not attempted in most recent-onset episodes. Methods to improve rate-control effectiveness, the selection of patients for rhythm control, and the use of electrocardioversion appear warranted.