Trial of an Intervention to Improve Acute Heart Failure Outcomes.

BACKGROUND: Patients with acute heart failure are frequently or systematically hospitalized, often because the risk of adverse events is uncertain and the options for rapid follow-up are inadequate. Whether the use of a strategy to support clinicians in making decisions about discharging or admitting patients, coupled with rapid follow-up in an outpatient clinic, would affect outcomes remains uncertain. METHODS: In a stepped-wedge, cluster-randomized trial conducted in Ontario, Canada, we randomly assigned 10 hospitals to staggered start dates for one-way crossover from the control phase (usual care) to the intervention phase, which involved the use of a point-of-care algorithm to stratify patients with acute heart failure according to the risk of death. During the intervention phase, low-risk patients were discharged early (in ≤3 days) and received standardized outpatient care, and high-risk patients were admitted to the hospital. The coprimary outcomes were a composite of death from any cause or hospitalization for cardiovascular causes within 30 days after presentation and the composite outcome within 20 months. RESULTS: A total of 5452 patients were enrolled in the trial (2972 during the control phase and 2480 during the intervention phase). Within 30 days, death from any cause or hospitalization for cardiovascular causes occurred in 301 patients (12.1%) who were enrolled during the intervention phase and in 430 patients (14.5%) who were enrolled during the control phase (adjusted hazard ratio, 0.88; 95% confidence interval [CI], 0.78 to 0.99; P = 0.04). Within 20 months, the cumulative incidence of primary-outcome events was 54.4% (95% CI, 48.6 to 59.9) among patients who were enrolled during the intervention phase and 56.2% (95% CI, 54.2 to 58.1) among patients who were enrolled during the control phase (adjusted hazard ratio, 0.95; 95% CI, 0.92 to 0.99). Fewer than six deaths or hospitalizations for any cause occurred in low- or intermediate-risk patients before the first outpatient visit within 30 days after discharge. CONCLUSIONS: Among patients with acute heart failure who were seeking emergency care, the use of a hospital-based strategy to support clinical decision making and rapid follow-up led to a lower risk of the composite of death from any cause or hospitalization for cardiovascular causes within 30 days than usual care. (Funded by the Ontario SPOR Support Unit and others; COACH ClinicalTrials.gov number, NCT02674438.).

Ambulatory Cardiology or General Internal Medicine Assessment Prior to Scheduled Major Vascular Surgery is Associated with Improved Outcomes.

OBJECTIVE: To characterize the association between ambulatory cardiology or general internal medicine (GIM) assessment prior to surgery and outcomes following scheduled major vascular surgery. BACKGROUND: Cardiovascular risk assessment and management prior to high-risk surgery remains an evolving area of care. METHODS: This is population-based retrospective cohort study of all adults who underwent scheduled major vascular surgery in Ontario, Canada, April 1, 2004-March 31, 2019. Patients who had an ambulatory cardiology and/or GIM assessment within 6 months prior to surgery were compared to those who did not. The primary outcome was 30-day mortality. Secondary outcomes included: composite of 30-day mortality, myocardial infarction or stroke; 30-day cardiovascular death; 1-year mortality; composite of 1-year mortality, myocardial infarction or stroke; and 1-year cardiovascular death. Cox proportional hazard regression using inverse probability of treatment weighting (IPTW) was used to mitigate confounding by indication. RESULTS: Among 50,228 patients, 20,484 (40.8%) underwent an ambulatory assessment prior to surgery: 11,074 (54.1%) with cardiology, 8,071 (39.4%) with GIM and 1,339 (6.5%) with both. Compared to patients who did not, those who underwent an assessment had a higher Revised Cardiac Risk Index (N with Index over 2= 4,989[24.4%] vs. 4,587[15.4%], P<0.001) and more frequent pre-operative cardiac testing (N=7,772[37.9%] vs. 6,113[20.6%], P<0.001) but, lower 30-day mortality (N=551[2.7%] vs. 970[3.3%], P<0.001). After application of IPTW, cardiology or GIM assessment prior to surgery remained associated with a lower 30-day mortality (weighted Hazard Ratio [95%CI] = 0.73 [0.65-0.82]) and a lower rate of all secondary outcomes. CONCLUSIONS: Major vascular surgery patients assessed by a cardiology or GIM physician prior to surgery have better outcomes than those who are not. Further research is needed to better understand potential mechanisms of benefit.

Comparison of machine learning and conventional statistical modeling for predicting readmission following acute heart failure hospitalization.

INTRODUCTION: Developing accurate models for predicting the risk of 30-day readmission is a major healthcare interest. Evidence suggests that models developed using machine learning (ML) may have better discrimination than conventional statistical models (CSM), but the calibration of such models is unclear. OBJECTIVES: To compare models developed using ML with those developed using CSM to predict 30-day readmission for cardiovascular and noncardiovascular causes in HF patients. METHODS: We retrospectively enrolled 10,919 patients with HF (> 18 years) discharged alive from a hospital or emergency department (2004-2007) in Ontario, Canada. The study sample was randomly divided into training and validation sets in a 2:1 ratio. CSMs to predict 30-day readmission were developed using Fine-Gray subdistribution hazards regression (treating death as a competing risk), and the ML algorithm employed random survival forests for competing risks (RSF-CR). Models were evaluated in the validation set using both discrimination and calibration metrics. RESULTS: In the validation sample of 3602 patients, RSF-CR (c-statistic=0.620) showed similar discrimination to the Fine-Gray competing risk model (c-statistic=0.621) for 30-day cardiovascular readmission. In contrast, for 30-day noncardiovascular readmission, the Fine-Gray model (c-statistic=0.641) slightly outperformed the RSF-CR model (c-statistic=0.632). For both outcomes, The Fine-Gray model displayed better calibration than RSF-CR using calibration plots of observed vs predicted risks across the deciles of predicted risk. CONCLUSIONS: Fine-Gray models had similar discrimination but superior calibration to the RSF-CR model, highlighting the importance of reporting calibration metrics for ML-based prediction models. The discrimination was modest in all readmission prediction models regardless of the methods used.

Trajectories of P2Y12 inhibitor adherence in patients with acute coronary syndromes.

PURPOSE: P2Y12 inhibitors (P2Y12i) reduce cardiac events after acute coronary syndromes (ACS). However, suboptimal P2Y12i adherence persists. We aimed to examine P2Y12i non-adherence using group-based trajectory methods and to identify adherence predictors. METHODS: We conducted a population-based, retrospective cohort study using administrative data in Ontario, Canada of patients ≥65 years admitted for ACS between April 2014 and March 2018 with a P2Y12i dispensed within 7 days of discharge. We used group-based trajectory models to characterize longitudinal 1-year adherence patterns. Predictors associated with each adherence trajectory were identified by multinomial logistic regression. RESULTS: We included 11 917 patients using clopidogrel and 9763 using ticagrelor, aged [mean ± SD]: 77.33 ± 8.31/73.59 ± 6.79 years; men: 56.2%/65.4%, respectively. We identified 3 longitudinal adherence trajectories, that differed by agent: 75% of clopidogrel and 68% of ticagrelor patients showed a consistently adherent trajectory, while 13%/17% were gradually, and 12%/15% were rapidly non-adherent, respectively (p < 0.001). Differing baseline characteristics in each cohort were associated with observed adherence trajectories. Concomitant atrial fibrillation and prior bleeding history were associated with non-adherence among clopidogrel users. Among ticagrelor users, women and older persons were more likely to be rapidly non-adherent, adherence declining steeply starting 1 month post-ACS. CONCLUSIONS: We identified distinct adherence trajectories for clopidogrel and ticagrelor post-ACS, with 3 out of 4 clopidogrel patients but only 2 out of 3 ticagrelor patients in the consistently adherent trajectory. Intensive interventions targeted to the period of steep adherence decline post-ACS, particularly for women and older persons initiating ticagrelor, and patients with atrial fibrillation on clopidogrel should be considered and investigated further.

Rationale and design of the comparison of outcomes and access to care for heart failure (COACH) trial: A stepped wedge cluster randomized trial.

BACKGROUND: Heart failure (HF) is an ambulatory care sensitive condition and a leading reason for emergency department (ED) visits and hospitalizations. Improved decision-making and care may enhance safety and efficiency for patients presenting to the ED with acute HF. OBJECTIVES: We will evaluate an intervention comprised of 2 complementary components: (1) the Emergency Heart Failure Mortality Risk Grade simultaneous 7- and 30-day (EHMRG30-ST) risk scores, which will inform admission-discharge decisions, and (2) a rapid outpatient follow-up (RAPID-HF) clinic for low-to-intermediate risk patients on cardiovascular readmissions or death. STUDY DESIGN: Stepped wedge cluster randomized trial with cross-sectional measurement at 10 acute care hospitals in Ontario, Canada. Patients presenting during control and intervention periods are eligible if they have a primary ED diagnosis of HF. In the intervention periods, access to the EHMRG30-ST web calculator will become available to hospitals' internet protocol (IP) addresses, and referral to the RAPID-HF clinic will be facilitated by a study nurse navigator. Patients with a high risk EHMRG30-ST score will be admitted to hospital. The RAPID-HF clinic will accept referrals for patients: (1) with low risk 7- and 30-day EHMRG30-ST scores who are discharged directly from the ED, or (2) intermediate risk patients with hospital length of stay < 72 hours. The RAPID-HF clinic, staffed by a nurse-clinician and cardiologist, will provide care during the 30-day transition after hospital separation. CONCLUSION: This trial will determine whether novel risk stratification coupled with rapid ambulatory care achieves better outcomes than conventional decision-making and care for patients with HF.

Current Status and Future of BI-RADS in Multimodality Imaging, From the AJR Special Series on Radiology Reporting and Data Systems.

BI-RADS is a communication and data tracking system that has evolved since its inception as a brief mammography lexicon and reporting guide into a robust structured reporting platform and comprehensive quality assurance tool for mammography, ultrasound, and MRI. Consistent and appropriate use of the BI-RADS lexicon terminology and assessment categories effectively communicates findings, estimates the risk of malignancy, and provides management recommendations to patients and referring clinicians. The impact of BI-RADS currently extends internationally through six language translations. A condensed version has been proposed to facilitate a phased implementation of BI-RADS in resource-constrained regions. The primary advance of the 5th edition of BI-RADS is harmonization of the lexicon terms across mammography, ultrasound, and MRI. Harmonization has also been achieved across these modalities for the reporting structure, assessment categories, management recommendations, and data tracking system. Areas for improvement relate to certain common findings that lack lexicon descriptors and a need for further clarification of proper use of category 3. BI-RADS is anticipated to continue to evolve for application to a range of emerging breast imaging modalities.

Cutaneous intralymphatic anaplastic lymphoma kinase-negative anaplastic large-cell lymphoma arising in a patient with multiple rounds of breast implants.

Primary cutaneous anaplastic large-cell lymphoma and breast implant-associated ALCL (BIA-ALCL) are rare subtypes of anaplastic lymphoma kinase (ALK)-negative ALCLs originating from skin and breast implants, respectively. Herein, we report a unique case of cutaneous ALK-negative ALCL occurring in the skin of left medial breast from a patient with multiple rounds of bilateral breast implants and a history of breast carcinoma. The lymphoma cells are entirely confined to the lymphatic channels in the dermis, and the patient has no other areas of skin abnormality, no lymphadenopathy, peri-implant fluid accumulation, or masses from the bilateral capsules of implants. The differential diagnosis and its relationship with breast implants are further explored.

Benefits of volunteering on psychological well-being in older adulthood: evidence from a randomized controlled trial.

Objectives: Long-term volunteering has been associated with better physical, mental, and cognitive health in correlational studies. Few studies, however, have examined the longitudinal benefits of volunteering with randomized experimental designs (e.g., intervention studies). Even fewer studies have examined whether such benefits can be shown after short-term volunteering. To fill this gap, we conducted four 1-hour volunteering intervention sessions to promote volunteering among a group of older adults with limited volunteering experience and examined the impact of volunteering on depressive symptoms, meaning in life, general self-efficacy, and perceived autonomy.Methods: A total of 384 participants aged 50-96 years were assigned at random to either an intervention group to promote volunteering behaviors or an active control group to promote physical activity. The participants' monthly volunteering minutes, depressive symptoms, meaning in life, general self-efficacy and perceived autonomy were measured at baseline and six weeks, three months, and six months after the intervention.Results: Being in the volunteering intervention condition was not directly associated with depressive symptoms, meaning in life, general self-efficacy, or perceived autonomy at the 6-week, 3-month, or 6-month follow-ups after the intervention. However, there was an indirect effect of the intervention on depressive symptoms: participants in the intervention group, who had increased their volunteering at the 3-month follow-up, reported fewer depressive symptoms at the 6-month follow-up.Discussion: Our randomized controlled trial suggests that short-term volunteering does not reliably lead to short-term changes in psychosocial health measures as correlational studies would suggest. Efforts need to be made to encourage older adults to maintain long-term volunteering.

Prospective Validation of the Emergency Heart Failure Mortality Risk Grade for Acute Heart Failure.

BACKGROUND: Improved risk stratification of acute heart failure in the emergency department may inform physicians' decisions regarding patient admission or early discharge disposition. We aimed to validate the previously-derived Emergency Heart failure Mortality Risk Grade for 7-day (EHMRG7) and 30-day (EHMRG30-ST) mortality. METHODS: We conducted a multicenter, prospective validation study of patients with acute heart failure at 9 hospitals. We surveyed physicians for their estimates of 7-day mortality risk, obtained for each patient before knowledge of the model predictions, and compared these with EHMRG7 for discrimination and net reclassification improvement. We also prospectively examined discrimination of the EHMRG30-ST model, which incorporates all components of EHMRG7 as well as the presence of ST-depression on the 12-lead ECG. RESULTS: We recruited 1983 patients seeking emergency department care for acute heart failure. Mortality rates at 7 days in the 5 risk groups (very low, low, intermediate, high, and very high risk) were 0%, 0%, 0.6%, 1.9%, and 3.9%, respectively. At 30 days, the corresponding mortality rates were 0%, 1.9%, 3.9%, 5.9%, and 14.3%. Compared with physician-estimated risk of 7-day mortality (PER7; c-statistic, 0.71; 95% CI, 0.64-0.78) there was improved discrimination with EHMRG7 (c-statistic, 0.81; 95% CI, 0.75-0.87; P=0.022 versus PER7) and with EHMRG7 combined with physicians' estimates (c-statistic, 0.82; 95% CI, 0.76-0.88; P=0.003 versus PER7). Model discrimination increased nonsignificantly by 0.014 (95% CI, -0.009-0.037) when physicians' estimates combined with EHMRG7 were compared with EHMRG7 alone ( P=0.242). The c-statistic for EHMRG30-ST alone was 0.77 (95% CI, 0.73-0.81) and 30-day model discrimination increased nonsignificantly by addition of physician-estimated risk to 0.78 (95% CI, 0.73-0.82; P=0.187). Net reclassification improvement with EHMRG7 was 0.763 (95% CI, 0.465-1.062) when assessed continuously and 0.820 (0.560-1.080) using risk categories compared with PER7. CONCLUSIONS: A clinical model allowing simultaneous prediction of mortality at both 7 and 30 days identified acute heart failure patients with a low risk of events. Compared with physicians' estimates, our multivariable model was better able to predict 7-day mortality and may guide clinical decisions. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02634762.

Digital Breast Tomosynthesis: Concepts and Clinical Practice.

Digital breast tomosynthesis (DBT) is emerging as the standard of care for breast imaging based on improvements in both screening and diagnostic imaging outcomes. The additional information obtained from the tomosynthesis acquisition decreases the confounding effect of overlapping tissue, allowing for improved lesion detection, characterization, and localization. In addition, the quasi three-dimensional information obtained from the reconstructed DBT data set allows a more efficient imaging work-up than imaging with two-dimensional full-field digital mammography alone. Herein, the authors review the benefits of DBT imaging in screening and diagnostic breast imaging.

Prescribing of oral anticoagulants in the emergency department and subsequent long-term use by older adults with atrial fibrillation.

BACKGROUND: Patients with atrial fibrillation frequently seek emergency care. Rates of guideline-concordant oral anticoagulant therapy for stroke prevention are suboptimal in the community. We assessed the association between prescribing of oral anticoagulants in the emergency department (relative to referral to a longitudinal care provider for treatment initiation) and long-term use of oral anticoagulants. METHODS: This retrospective cohort study performed at 15 hospitals in Ontario, Canada, involved patients aged 65 years or older who visited the emergency department between 2009 and 2014, who had a primary diagnosis of atrial fibrillation, were discharged home, and were eligible for and willing to take stroke-prevention therapy. We used inverse probability-of-treatment weighting based on the propensity score to compare patients who were and were not given a prescription for an oral anticoagulant. The primary outcome was a prescription fill for an oral anticoagulant 6 months later. Secondary outcomes included a prescription fill at 1 year, all-cause mortality, and strokes or bleeding events leading to hospital admission. RESULTS: Of 2132 eligible patients, 402 (18.9%) were given a prescription for an oral anticoagulant in the emergency department. After weighting, 67.8% of these patients had filled a prescription for an oral anticoagulant at 6 months versus 37.2% of those who did not receive a prescription in the emergency department (absolute risk increase [ARI] 30.6%, number needed to treat [NNT] 3). At 1 year, the ARI was 23.2% and the NNT was 4. Rates of death, stroke and bleeding events did not differ significantly. INTERPRETATION: In patients with atrial fibrillation who were eligible for stroke prevention, prescribing an oral anticoagulant in the emergency department was associated with substantially higher long-term use of oral anticoagulants compared with deferring to the longitudinal care provider to initiate this therapy. Physicians working in the emergency department should consider initiating oral anticoagulation in eligible patients who are being discharged to home.

Study protocol of a multi-center RCT testing a social-cognitive intervention to promote volunteering in older adults against an active control.

BACKGROUND: Volunteering could be a win-win opportunity for older adults: Links between volunteering and societal improvements as well as older adults' own health and longevity are found in several observational studies. RCTs to increase volunteering in older adults are however sparse, leaving the question of causality unanswered. This study protocol describes a theory-based social-cognitive intervention with multiple behavior change techniques to increase volunteering among community-dwelling older adults in Hong Kong. METHODS: In a parallel group, two-arm, randomized controlled trial, an initial N = 360 are assigned to receive either the volunteering intervention or the active control intervention (parallel content targeting physical activity). The primarily outcome measure is self-reported volunteering minutes per month at baseline, six weeks, three months and six months after the intervention. Participants in the treatment group are expected to increase their weekly volunteering minutes over time as compared to participants in the control group. Possible active ingredients of the intervention as well as mental and physical health outcomes of increased volunteering are investigated by means of mediation analyses. DISCUSSION: Like many industrialized nations, Hong Kong faces a rapid demographic change. An effective psychological intervention to encourage retirees to engage in formal volunteering would alleviate some of the societal challenges a growing proportion of older adults entails. TRIAL REGISTRATION: Primary Registry and Trial Identifying Number ChiCTR-IIC-17010349 , secondary CCRB trial number CUHK_CCRB00543, registration date 2016/12/28.

A clinical decision instrument to predict 30-day death and cardiovascular hospitalizations after an emergency department visit for atrial fibrillation: The Atrial Fibrillation in the Emergency Room, Part 2 (AFTER2) study.

BACKGROUND: In previous work, we derived and validated a tool that predicts 30-day mortality in emergency department atrial fibrillation (AF) patients. The objective of this study was to derive and validate a tool that predicts a composite of 30-day mortality and return cardiovascular hospitalizations. METHODS: This retrospective cohort study at 24 emergency departments in Ontario, Canada, included patients with a primary diagnosis of AF who were seen between April 2008 and March 2009. We assessed a composite outcome of 30-day mortality and subsequent hospitalizations for a cardiovascular reason, including stroke. RESULTS: Of 3,510 patients, 2,343 were randomly selected for the derivation cohort, leaving 1,167 in the validation cohort. The composite outcome occurred in 227 (9.7%) and 125 (10.7%) patients in the derivation and validation cohorts, respectively. Eleven variables were independently associated with the outcome: older age, not taking anticoagulation, HAS-BLED score of ≥3, 3 laboratory results (positive troponin, supratherapeutic international normalized ratio, and elevated creatinine), emergency department administration of furosemide, and 4 patient comorbidities (heart failure, chronic obstructive lung disease, cancer, dementia). In the validation cohort, the observed 30-day outcomes in the 5 risk strata that were defined using the derivation cohort were 2.0%, 6.6%, 10.7%, 12.5%, and 20.0%. The c statistic was 0.73 and 0.69 in the derivation and validation cohort, respectively. CONCLUSIONS: Using a population-based sample, we derived and validated a tool that predicts the risk of early death and rehospitalization for a cardiovascular reason in emergency department AF patients. The tool can offer information to managing physicians about the risk of death and rehospitalization for AF patients seen in the in emergency department, as well as identify patient groups for future targeted interventions aimed at preventing these outcomes.

Neighborhood Environment, Residential Satisfaction, and Depressive Symptoms Among Older Adults in Residential Care Homes.

Burgeoning evidence has shown that neighborhood environments are related to depressive symptoms in the older population. Older adults living in residential care homes may be more vulnerable to environmental characteristics. The current study sought to understand how institutionalized older adults relate to environmental factors and residential satisfaction in terms of depressive symptoms. Data were collected from a cross-sectional national survey of 1,429 Chinese elders living in residential care homes. The findings reveal that 46.1% of the older Chinese residents living in residential care homes suffered from mild to severe depression. In addition, the current study finds that both environmental factors (e.g., geographic position, air quality, and transportation) and residential satisfaction are negatively associated with depressive symptoms. The findings support that residential satisfaction partially mediate the relationship between exterior environmental characteristics and depressive symptoms.

Can domestic helpers moderate distress of offspring caregivers of cognitively impaired older adults?

OBJECTIVE: This study examined the moderating effect of domestic helpers on distress of offspring caring for parents with cognitive impairments and with or without behavioural problems. METHOD: This secondary analysis of data involved 5086 Hong Kong Chinese adults aged 60 or older applying for public long-term care services from 2010 to 2012. All variables were measured using the mandatory Hong Kong version of the Minimum Data Set-Home Care 2.0. RESULTS: Regarding taking care of parents with cognitive impairments, 10.7% of offspring primary caregivers were aided by domestic helpers, 55.54% reported distress, and 75.70% lived with their parents. Assistance from domestic helpers reduced offspring caregiver distress if the offspring provided psychological support to parents (ratio of OR = 0.655, p < .05) and were not living with parents (ratio of OR = 1.183, p < .01). CONCLUSION: These findings might suggest: a) the positive effects of audience on psychological responses to stress; b) caregiving is usually less stressful for informal caregivers not residing with care recipients. Conversely, having a domestic helper could add to caregiving distress if offspring caregivers live with their parents, most likely because offspring may witness difficulties that domestic helpers face in providing dementia care.

The Long-Term Use of Warfarin Among Atrial Fibrillation Patients Discharged From an Emergency Department With a Warfarin Prescription.

STUDY OBJECTIVE: The optimal timing to begin stroke prevention therapy in patients being discharged from an emergency department (ED) with atrial fibrillation is not known. We determined whether eligible patients who were provided with an ED prescription for oral anticoagulation had better rates of long-term anticoagulation use than eligible patients who were referred to their primary care provider for further care. METHODS: As part of a historical cohort study, in this planned substudy we abstracted data from patient charts with a primary diagnosis of atrial fibrillation from 24 EDs between April 1, 2008, and March 31, 2009. In the current study, discharged patients aged 65 years and older who had a CHADS2 score greater than or equal to 2 and a HAS-BLED score less than 3, with no history of falls and who were not receiving oral anticoagulation when they presented to the ED, were included. We compared the frequency of warfarin use at 6 months and 1 year after ED discharge for patients who were given a prescription for warfarin before they left the ED to those who were not. RESULTS: Among 137 qualifying patients, 33 (24.1%) were provided with a warfarin prescription before discharge from the ED. At 6 months, 25 of the 33 were still receiving warfarin, compared with 34 of 104 among the patients who were not given an ED prescription (absolute difference, 43.1%; 95% confidence interval [CI] 23.8 to 57.2). At 1 year, 75.8% versus 35.6% (absolute difference, 40.2%; 95% CI 20.9 to 54.4) were receiving warfarin, respectively. Among the patients who filled a prescription for warfarin, the mean number of days from ED discharge until a warfarin prescription was filled was 6.0 (SD 21.3) for patients who were provided with an ED prescription compared with 205 (SD 377) for those who were not. CONCLUSION: Among ED patients who met criteria for guideline-recommended use of stroke prevention therapy, those who received an initial prescription in the ED had a higher frequency of long-term warfarin use than those for whom the decision to initiate therapy was referred to another care provider.

A Clinical Decision Instrument for 30-Day Death After an Emergency Department Visit for Atrial Fibrillation: The Atrial Fibrillation in the Emergency Room (AFTER) Study.

STUDY OBJECTIVE: The high volume of patients treated in an emergency department (ED) for atrial fibrillation is predicted to increase significantly in the next few decades. Currently, 11% of these patients die within a year. We sought to derive and validate a complex model and a simplified model that predicts mortality in ED patients with atrial fibrillation. METHODS: This population-based, retrospective cohort study included 3,510 adult patients with a primary diagnosis of atrial fibrillation who were treated at 24 hospital EDs in Ontario, Canada, between April 2008 and March 2009. The main outcome was 30-day all-cause mortality. RESULTS: In the derivation cohort (n=2,343; mean age 68.8 years), 2.6% of patients died within 30 days of the ED visit versus 2.7% in the validation cohort (n=1,167; mean age 68.3 years). Variables associated with mortality in the complex model included age, presenting pulse rate and systolic blood pressure, presence of chest pain, 2 laboratory results (positive troponin result and creatinine level greater than 200 µmol [2.26 mg/dL]), 4 comorbidities (smoking, chronic obstructive pulmonary disease, cancer, and dementia), an increased bleeding risk, and a second acute ED diagnosis (in addition to atrial fibrillation). Observed 30-day mortality in the 5 risk strata that were defined by the predicted probability of death were 0.44%, 0.41%, 0.23%, 1.61%, and 10.3%. The c statistics were 0.88 and 0.87 in the derivation and validation cohorts, respectively. The a priori-selected 6-variable model, TrOPs-BAC, included a positive Troponin result, Other acute ED diagnosis, Pulmonary disease (chronic obstructive pulmonary disease), Bleeding risk, Aged 75 years or older, and Congestive heart failure. The c statistic for the simplified model was 0.81 in both the derivation and validation cohorts. CONCLUSION: Using a population-based sample, we derived and validated both a complex and a simplified instrument that predicts mortality after an emergency visit for atrial fibrillation. These may aid clinicians in identifying high-risk patients for hospitalization while safely discharging more patients home.