Department of Emergency Medicine, St Paul's Hospital and the University of British Columbia, Vancouver, British Columbia, Canada.
Ann Emerg Med. 2013 Dec;62(6):557-565.e2. doi: 10.1016/j.annemergmed.2013.04.004. Epub 2013 May 24.
Emergency department (ED) patients with atrial fibrillation or flutter are at risk of stroke, and guidelines recommend anticoagulation for patients with increased cardiovascular risk. Emergency physicians have a unique opportunity to provide appropriate anticoagulation for such patients, and we wished to investigate whether this was accomplished.
This retrospective cohort study used a database from 2 urban EDs to identify consecutive patients with an ED discharge diagnosis of atrial fibrillation or flutter from April 1, 2006, to March 31, 2010, who were managed solely by the emergency physician. Comorbidities, rhythms, and management were obtained by chart review, and complicated patients (those with an acute underlying medical condition) were excluded by predefined criteria. Patient medications on ED presentations were obtained through the provincial Pharmanet database. Patients were stratified into CHADS 2 (congestive heart failure, hypertension, age > 75, diabetes, stroke/transient ischemic attack) scores, and the primary outcome was the proportion of higher-risk (CHADS 2 score >0) patients who were discharged home with the incorrect anticoagulation by the emergency physician. The secondary outcome was the number of lower-risk (CHADS 2=0) patients who began receiving warfarin by the emergency physician orders. The regional ED database was interrogated to ascertain the number of patients who had a stroke at 30 days.
Consecutive patients (1,090) were enrolled and 732 were discharged home with no cardiology consultation (657 fibrillation and 75 flutter). Of 151 higher-risk (CHADS 2 score >0) patients who should have been anticoagulated, 80 (53.0%; 95% confidence interval 44.7% to 61.0%) were discharged home from the ED without appropriate anticoagulation. In this group, 1 patient had an ischemic stroke at 24 days. Among 300 lower-risk patients (CHADS 2 score=0), 25 (8.3%; 95% confidence interval 5.6% to 12.2%) had warfarin initiated.
In this cohort of ED patients with uncomplicated atrial fibrillation or flutter who were discharged without cardiology involvement, many were not appropriately anticoagulated before ED arrival, and more than half of such patients did not appear to have corrective measures initiated by the emergency physician. This may represent a potential opportunity to improve patient care and outcomes.
急诊科（ED）患有心房颤动或扑动的患者存在中风风险，指南建议对心血管风险增加的患者进行抗凝治疗。急诊医生有机会为这些患者提供适当的抗凝治疗，我们希望对此进行研究。
本回顾性队列研究使用来自 2 家城市 ED 的数据库，确定 2006 年 4 月 1 日至 2010 年 3 月 31 日期间，ED 出院诊断为心房颤动或扑动的连续患者，这些患者仅由急诊医生管理。通过病历回顾获得合并症、节律和管理信息，并通过预定义标准排除复杂患者（有急性基础疾病的患者）。ED 就诊时患者的药物治疗情况通过省级 Pharmanet 数据库获得。患者根据 CHADS 2 评分（充血性心力衰竭、高血压、年龄＞75 岁、糖尿病、中风/短暂性脑缺血发作）进行分层，主要结局是急诊医生出院时为高风险（CHADS 2 评分＞0）患者开具的错误抗凝药物的比例。次要结局是急诊医生医嘱开始使用华法林的低风险（CHADS 2=0）患者人数。查询区域 ED 数据库以确定 30 天内发生中风的患者人数。
连续纳入 1090 例患者，其中 732 例出院，未进行心内科会诊（657 例为房颤，75 例为房扑）。在 151 例高风险（CHADS 2 评分＞0）患者中，有 80 例（53.0%；95%置信区间 44.7%至 61.0%）在 ED 出院时未接受适当的抗凝治疗。在这组患者中，有 1 例患者在 24 天发生缺血性中风。在 300 例低风险患者（CHADS 2 评分=0）中，有 25 例（8.3%；95%置信区间 5.6%至 12.2%）开始使用华法林。
在本队列中，ED 患者患有未复杂化的心房颤动或扑动，在未进行心内科会诊的情况下出院，其中许多患者在 ED 就诊前未接受适当的抗凝治疗，超过一半的此类患者似乎未接受急诊医生的纠正措施。这可能是改善患者护理和结局的潜在机会。
