Stiell Ian G, Clement Catherine M, Rowe Brian H, Brison Robert J, Wyse D George, Birnie David, Dorian Paul, Lang Eddy, Perry Jeffrey J, Borgundvaag Bjug, Eagles Debra, Redfearn Damian, Brinkhurst Jennifer, Wells George A
Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
Ann Emerg Med. 2017 May;69(5):562-571.e2. doi: 10.1016/j.annemergmed.2016.10.013. Epub 2017 Jan 19.
Recent-onset atrial fibrillation and flutter are the most common arrhythmias managed in the emergency department (ED). We evaluate the management and 30-day outcomes for recent-onset atrial fibrillation and flutter patients in Canadian EDs, where cardioversion is commonly practiced.
We conducted a prospective cohort study in 6 academic hospital EDs and enrolled patients who had atrial fibrillation and flutter onset within 48 hours. Patients were followed for 30 days by health records review and telephone. Adverse events included death, stroke, acute coronary syndrome, heart failure, subsequent admission, or ED electrocardioversion.
We enrolled 1,091 patients with mean age 63.9 years, atrial fibrillation 84.7%, atrial flutter 15.3%, hospital admission 9.0%, and converted to sinus rhythm 80.1%. Although 10.5% of recent-onset atrial fibrillation and flutter patients had adverse events within 30 days, there were no related deaths and 1 stroke (0.1%). Adjusted odds ratios for factors associated with adverse event were hours from onset (1.03/hour; 95% confidence interval [CI] 1.01 to 1.05), history of stroke or transient ischemic attack (2.09; 95% CI 1.01 to 4.36), and pulmonary congestion on chest radiograph (7.37; 95% CI 2.40 to 22.64). Patients who left the ED in sinus rhythm were much less likely to experience an adverse event (P<.001).
Although most recent-onset atrial fibrillation and flutter patients were treated aggressively in the ED, there were few 30-day serious outcomes. Physicians underprescribed oral anticoagulants. Potential risk factors for adverse events include longer duration from arrhythmia onset, previous stroke or transient ischemic attack, pulmonary congestion on chest radiograph, and not being in sinus rhythm at discharge. An ED strategy of sinus rhythm restoration and discharge in most patients is effective and safe.
近期发作的心房颤动和心房扑动是急诊科（ED）处理的最常见心律失常。我们评估了加拿大急诊科中近期发作的心房颤动和心房扑动患者的治疗情况及30天预后，在这些急诊科中，心脏复律是常用的治疗方法。
我们在6家学术医院的急诊科进行了一项前瞻性队列研究，纳入房颤和房扑发作在48小时内的患者。通过健康记录审查和电话随访患者30天。不良事件包括死亡、中风、急性冠状动脉综合征、心力衰竭、随后的入院或急诊科心脏复律。
我们纳入了1091例患者，平均年龄63.9岁，房颤占84.7%，房扑占15.3%，住院率为9.0%，转为窦性心律的比例为80.1%。虽然10.5%的近期发作的房颤和房扑患者在30天内出现不良事件，但无相关死亡病例，仅有1例中风（0.1%）。与不良事件相关因素的调整后比值比为发作后小时数（1.03/小时；95%置信区间[CI]1.01至1.05）、中风或短暂性脑缺血发作史（2.09；95%CI 1.01至4.36）以及胸部X线片显示的肺淤血（7.37；95%CI 2.40至22.64）。以窦性心律离开急诊科的患者发生不良事件的可能性要小得多（P<0.001）。
虽然大多数近期发作的房颤和房扑患者在急诊科得到了积极治疗，但30天内严重后果较少。医生口服抗凝药处方不足。不良事件的潜在危险因素包括心律失常发作时间较长、既往中风或短暂性脑缺血发作、胸部X线片显示肺淤血以及出院时未处于窦性心律。在大多数患者中恢复窦性心律并出院的急诊科策略是有效且安全的。
