Managing AF: A Look at Treating Specialty

Managing AF: A Look at Treating Specialty

About 2.3 million Americans are affected by atrial fibrillation and atrial flutter (AF), a condition that causes 15% of the 700,000 strokes that occur annually in the United States. Anticoagulants like warfarin can help prevent stroke in AF patients, but these therapies can also cause bleeding in some cases. “Prediction tools, such as the CHADS2 score, have been developed to estimate stroke risk and are now recommended by clinical guideline statements,” says Mintu P. Turakhia, MD, MAS. “These guidelines, however, vary considerably in describing how stroke and bleeding risk should be evaluated and integrated into clinical decision making.” Assessing Potential Variations in Warfarin Use It has been suspected that use of warfarin in AF may vary by specialty and over time. In the American Heart Journal, Dr. Turakhia and colleagues had a study published that evaluated differences and trends in warfarin prescription by treating specialty for new AF cases. Using VA data from the TREAT-AF study, the investigators reviewed more than 141,000 participants with newly diagnosed AF in which patients had at least one internal medicine, primary care, or cardiology encounter within 90 days of their diagnosis. The primary outcome was prescription of warfarin. According to results, care of patients with new AF from cardiologists appeared to be associated with a greater likelihood of warfarin prescription when compared with care only from primary care physicians (Table 1), even after adjusting for covariates and a propensity for cardiology care. The observation was also consistent across subgroups of patients, including those who were at lowest risk for bleeding. Furthermore, warfarin prescriptions were more frequently provided to those at highest risk for stroke,...

Managing Recent-Onset Atrial Fibrillation in the ED

Atrial fibrillation (AF) is the most common sustained cardiac rhythm disturbance. AF is a risk factor for ischemic stroke and heart failure, both of which represent significant public health problems. With an increasing prevalence among an aging population, symptomatic AF-related ED visits have been rising and will likely continue to rise. Traditionally, ED patients thought to have recent-onset AF have been hospitalized for monitoring and evaluation of more serious conditions. More recently, clinicians have been utilizing a more aggressive approach in which stable ED patients with presumed recent-onset AF are treated with elective cardioversion without anticoagulation. While previous reports suggest that this approach is associated with a high rate of cardioversion to sinus rhythm and a low rate of hospitalization and complications, there is no consensus on whether it is better than traditional approaches. Seeking Confirmation on Recent-Onset AF Treatment In the February 2012 Journal of Emergency Medicine, David R. Vinson, MD, and colleagues published a prospective multicenter study that describes the management of ED patients with presumed recent-onset AF. “It had been our anecdotal experience at three affiliated community EDs that taking an aggressive cardioversion approach to managing patients with recent-onset AF was effective and associated with few complications,” says Dr. Vinson. “In this study, we put our practice patterns under critical scrutiny to confirm the safety and effectiveness of ED cardioversion and to accurately measure the incidence of thromboembolism 30 days after discharge.” “Clinicians who are already practicing a more aggressive approach to restoring sinus rhythm can be reassured by the safety and efficacy that was observed in our study.” Dr. Vinson and colleagues analyzed 206 patients...