The Iowa less aggressive protocol: A mixed-methods study on the novel treatment protocol of atrial fibrillation.

OBJECTIVES: Atrial fibrillation is the most common cardiac dysrhythmia in the United States. Our aim was to determine if a novel protocol for management of atrial fibrillation was feasible to implement in an emergency department (ED). Interviews were conducted with ED physicians and physician assistants to identify themes in relation to the clinical use and impleon of the protocol. METHODS: A novel protocol was developed by a multi-disciplinary team and implemented in an academic ED. The protocol used cardiac computed tomography (CT) to rule out left atrial thrombus in patients with greater than 12 h of symptoms and high risk of thromboembolism, or any patient with greater than 48 h of symptoms. Patients who underwent cardiac CT or electrical cardioversion were followed up at 30 days via telephone to monitor for recurrence or adverse thromboembolic events. Providers were interviewed to identify themes regarding protocol usage, barriers to its use, and future changes to increase utilization. RESULTS: Patients with atrial fibrillation in the ED were eligible for inclusion. Twenty-nine patients were treated using the protocol. Seven patients (24%) underwent cardiac CT prior to electrical cardioversion. Cardioversion success rate was 83%, with 69% of patients discharged home. Thirty-day follow-up was completed on 25 patients (86%). Six patients (24%) had reoccurrence of atrial fibrillation requiring subsequent cardioversion. No patients experienced stroke or thromboembolic event. Interviews were conducted with 14 providers. Usage barriers included time, availability, and additional work-up. Six subthemes were identified for future changes including EMR order set, frequent reminders, increased education, increased awareness, activation energy, and EMR pop-ups. CONCLUSION: The Iowa Less Aggressive Protocol is a novel treatment protocol for the ED management of atrial fibrillation that was feasible to implement and use. Providers viewed the protocol favorably and identified areas of improvement for future use.

Two-Item Fall Screening Tool Identifies Older Adults at Increased Risk of Falling after Emergency Department Visit.

INTRODUCTION: Few emergency department (ED)-specific fall-risk screening tools exist. The goals of this study were to externally validate Tiedemann et al's two-item, ED-specific fall screening tool and test handgrip strength to determine their ability to predict future falls. We hypothesized that both the two-item fall screening and handgrip strength would identify older adults at increased risk of falling. METHODS: A convenience sample of patients ages 65 and older presenting to a single-center academic ED were enrolled. Patients were asked screening questions and had their handgrip strength measured during their ED visit. Patients were given one point if they answered "yes" to "Are you taking six or more medications?" and two points for answering "yes" to "Have you had two or more falls in the past year?" to give a cumulative score from 0 to 3. Participants had monthly follow- ups, via postcard questionnaires, for six months after their ED visit. We performed sensitivity and specificity analyses, and used likelihood ratios and frequencies to assess the relationship between risk factors and falls, fall-related injury, and death. RESULTS: In this study, 247 participants were enrolled with 143 participants completing follow-up (58%). During the six-month follow-up period, 34% of participants had at least one fall and 30 patients died (12.1%). Fall rates for individual Tiedemann scores were 14.3%, 33.3%, 60.0% and 72.2% for scores of 0,1, 2 and 3, respectively. Low handgrip strength was associated with a higher proportion of falls (46.3%), but had poor sensitivity (52.1%). CONCLUSION: Handgrip strength was not sensitive in screening older adults for future falls. The Tiedemann rule differentiated older adults who were at high risk for future falls from low risk individuals, and can be considered by EDs wanting to screen older adults for future fall risk.

New or presumed new left bundle branch block in patients with suspected ST-elevation myocardial infarction.

AIMS: Using a comprehensive large prospective regional ST-elevation myocardial infarction (STEMI) system database, we evaluated the prevalence, clinical and angiographic characteristics, and outcomes in patients with ischemic symptoms and new or presumed new left bundle branch block (LBBB). We then tested a new hierarchical diagnosis and triage algorithm to identify more accurately new LBBB patients with an acute culprit lesion. METHODS AND RESULTS: From March 2003 to June 2013, 3903 consecutive STEMI patients were treated using the Minneapolis Heart Institute regional STEMI protocol including 131 patients (3.3%) with new LBBB. These patients had fewer culprit arteries (54.2% vs. 86.4%; P<0.001), were older, more commonly women, with a lower ejection fraction, and more frequently presented with cardiac arrest or heart failure than those without new LBBB. At 1 year follow-up, all-cause mortality accounting for baseline differences was higher in patients with new LBBB (hazard ratio 1.73, 95% confidence interval 1.17-2.58; P=0.007). The new algorithm yielded high sensitivity (97%) and negative predictive value (94%) for identification of a culprit lesion. Using the definition of new LBBB with either hemodynamically unstable features or Sgarbossa concordance criteria on electrocardiogram (ECG), 45% of new LBBB patients would have been treated as 'STEMI equivalent'. CONCLUSION: Patients with acute ischemic symptoms and new LBBB represent a high-risk population with unique clinical challenges. If validated in an independent dataset, the new algorithm may improve the diagnostic accuracy regarding reperfusion therapy for new LBBB patients.

"No culprit" ST-elevation myocardial infarction: role of cardiac magnetic resonance imaging.

Patients with presumed ST-elevation myocardial infarction (STEMI) have no clear culprit artery in approximately 10-15% of cases. We examined the value of cardiac magnetic resonance (CMR) for diagnosis in patients with "no culprit" STEMI. Data from a comprehensive prospective registry of STEMI patients were reviewed from March 2003 to December 2009. "No culprit" patients were followed for diagnosis and clinical outcome. CMR was performed at the discretion of the attending cardiologist. Of 2728 consecutive presumed STEMI patients, 412 (15%) had no clear culprit artery. Of these, 202 (49%) had abnormal cardiac biomarkers with a definitive diagnosis in 157 (78%). Diagnoses in this group included myocardial infarction without a culprit lesion (24%), myopericarditis (22%), and stress cardiomyopathy (21%). In 210 (51%) patients with normal biomarkers, only 84 (40%) received a definitive diagnosis. Diagnoses in this group included myopericarditis (27%), noncardiac causes (21%), and cardiomyopathy (14%). CMR was performed in 123 (30%) "no culprit" patients. Patients who had CMR were more likely to have a definitive diagnosis than those who did not (95/123 [77%] vs. 144/289 [50%]; P=0.01). In particular, "no culprit" patients with abnormal biomarkers were more likely to have a definitive diagnosis with CMR. CMR led to a diagnosis different from the presumptive clinical diagnosis in 53% of all cases. CMR is a valuable diagnostic tool to improve diagnostic accuracy in patients with "no culprit" STEMI.