The burden of atrial fibrillation in unselected acute medical admissions.

BACKGROUND: Atrial fibrillation (AF) is the most common cardiac arrhythmia and is of increasing prevalence. The presence of AF complicates the management of patients presenting as medical emergencies. OBJECTIVE: To assess the prevalence of AF and current investigation and management strategies in unselected acute medical admissions. DESIGN: Prospective survey of all acute medical admissions over 22 days. SETTING: Stobhill Hospital--district general hospital in north Glasgow. SUBJECTS: Five hundred and seven consecutive acute medical admissions. RESULTS: Of the 507 patients, 47 (9.3%) had AF. AF was a new diagnosis in five patients (11.0%). The most common presenting features were dyspnoea and chest pain. The principal underlying medical conditions were hypertension and ischaemic heart disease. AF was the primary reason for admission in six patients (12.8%) and a documented reason for admission in 11 patients (23.4%). Thyroid function tests were or had previously been performed in 45 patients (95.7%). Twenty-four patients (51.1%) underwent echocardiography or had done so previously. Twenty-two patients (46.8%) received anticoagulation with warfarin. Ten patients (21.3%) should have received warfarin by standard guidelines but did not. No patient received warfarin inappropriately. Rate control was used in 40 patients (85.1%). Rhythm control was attempted in four patients (8.5%). CONCLUSION: AF is common amongst emergency admissions to district general hospitals and has significant resource implications. Improvements are needed both in the use of echocardiography and in the administration of anticoagulant therapy.

Key issues in the management of atrial fibrillation--protecting the patient and controlling the arrhythmia.

Atrial fibrillation (AF) is the most common sustained tachyarrhythmia and its prevalence is increasing. It is an independent risk factor for stroke and is associated with significant morbidity and mortality. AF currently accounts for 1% of NHS expenditure. The management of AF has a broad evidence base and both the American College of Cardiology/American Heart Association/European Society of Cardiology (ACC/AHA/ESC) and the National Institute for Clinical Excellence (NICE) have recently published guidelines. Some controversy persists regarding stroke risk stratification and appropriate anticoagulation regimes although a general consensus is now emerging. Rate and rhythm control strategies have been shown to be comparable in terms of clinical outcomes. Current anti-arrhythmic drugs have limited efficacy and significant side-effect profiles. Electrophysiological and surgical interventions have a role in both strategies. This article broadly reviews the evidence for different management strategies in AF and presents a practical approach to treatment in light of the recently published national and international guidelines.

Limited clinical utility of CT coronary angiography in a district hospital setting.

BACKGROUND: Studies have demonstrated considerable accuracy of multi-slice CT coronary angiography (MSCT-CA) in comparison to invasive coronary angiography (I-CA) for evaluating coronary artery disease (CAD). The extent to which published MSCT-CA accuracy parameters are transferable to routine practice beyond high-volume tertiary centres is unknown. AIM: To determine the accuracy of MSCT-CA for the detection of CAD in a Scottish district general hospital. DESIGN: Prospective study of diagnostic accuracy. METHOD: One hundred patients with suspected CAD recruited from two Glasgow hospitals underwent both MSCT-CA (Philips Brilliance 40 × 0.625 collimation, 50-200 ms temporal resolution) and I-CA. Studies were reported by independent, blinded radiologists and cardiologists and compared using the AHA 15-segment model. RESULTS: Of 100 patients [55 male, 45 female, mean (SD) age 58.0 (10.7) years], 59 and 41% had low-intermediate and high pre-test probabilities of significant CAD, respectively. Mean (SD) heart rate during MSCT-CA was 68.8 (9.0) bpm. Fifty-seven per cent of patients had coronary artery calcification and 35% were obese. Patient prevalence of CAD was 38%. Per-patient sensitivity, specificity, positive and negative (NPV) predictive values for MSCT-CA were 92.1, 47.5, 52.2 and 90.6%, respectively. NPV was reduced to 75.0% in the high pre-test probability group. Specificity was compromised in patients with sub-optimally controlled heart rates, calcified arteries and elevated BMI. CONCLUSION: Forty-Slice MSCT-CA has a high NPV for ruling out significant CAD when performed in a district hospital setting in patients with low-intermediate pre-test probability and minimal arterial calcification. Specificity is compromised by clinically appropriate strategies for dealing with unevaluable studies. Effective heart rate control during MSCT-CA is imperative. National guidelines should be utilized to govern patient selection and direct MSCT-CA reporter training to ensure quality control.