Standardized referral protocol from ED may improve care in AF
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A standardized referral protocol involving the electrophysiology service improved use of optimal therapy in patients with atrial fibrillation presenting to the ED compared with routine care, researchers reported at Heart Rhythm 2022.
Dhanunjaya R. Lakkireddy, MD, FACC, FHRS, medical director of the Kansas City Heart Rhythm Institute at HCA Midwest Health, and colleagues conducted the prospective, observational ER2EP study of 400 patients presenting with new-onset AF to the ED.
“Emergency rooms are one of the most important entry points for patients with atrial fibrillation; this is how a lot of them enter the health system,” Lakkireddy said during a press conference. “There is a tremendous amount of heterogeneity in the paths taken by these people in terms of how many of them get to see a cardiologist or electrophysiologist. How can we standardize care pathways for these people, providing them improved, faster access to definitive therapies? We believe emergency room physicians have a terrific opportunity to change the paradigm ... by tweaking their workflow a little, we could be able to accomplish significant short- and long-term differences in patients that have atrial fibrillation.”
In half of the hospitals in the study, the researchers introduced an automatic electrophysiology consultation (inpatient if the patient is admitted, outpatient if the patient is discharged) mediated through the ED. In the other half, care of patients with AF presenting to the ED remained the same as before.
The primary outcome was time to definitive therapy, including use of anticoagulation, antiarrhythmic drugs and radiofrequency catheter ablation. Follow-up occurred for 12 months. In the intervention group, the mean age was 75 years and 53% were men. In the control group, the mean age was 73 years and 51% were men.
“As we predicted, we had a significantly shorter time to definitive therapy and access to electrophysiologists” in the intervention group, Lakkireddy said during the press conference, noting that the median time to electrophysiologist evaluation was 1 day in the intervention group and 128 days in the control group (P = .001).
“Simple interventions in patient flow can change the overall outcomes in AFib care,” Lakkireddy told Healio.
Time to ablation (intervention, 52.8 days; control, 180.6 days; P < .001), antiarrhythmic drug use (intervention, 2.7 days; control, 25 days; P < .001) and oral anticoagulation use (intervention, 1.7 days; control, 17 days; P = .002) were all shorter in the intervention group, as was length of hospital stay (2.35 days vs. 5.84 days; P < .001), he said.
At 12 months, compared with the control group, the intervention group had fewer ED visits for heart-related issues (5% vs. 10%; P < .001), hospitalizations (0.97 per patient vs. 1.46 per patient; P < .001) and visits for congestive HF (4% vs. 8%; P = .05), but there were no differences between the groups in number of clinic visits, number of cardioversions, strokes or bleeding complications, according to the researchers.
“The most important messages are that early involvement of a specialist leads to significant improvement in access to therapy, initiation of guideline based therapy, ablation, reduced hospital admissions and heart failure admissions, and trends for reduction in stroke,” Lakkireddy told Healio.
“A simple intervention that is relatively non-labor intensive can open up an opportunity for patients to get faster and improved care, thereby impacting the short-term as well as the long-term outcomes and bringing in a paradigm shift in the way we can tackle atrial fibrillation,” Lakkireddy said during the press conference. “This is something that would be extremely important for health care systems to recognize and consider in our continued effort toward improving outcomes for our patients.”
The next step is to evaluate the protocol in larger cohorts, Lakkireddy told Healio.
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Lakkireddy D, et al. Late-Breaking Clinical Trials: Updates and Registries. Presented at: Heart Rhythm 2022; April 29-May 1, 2022; San Francisco (hybrid meeting).
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