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Emergency department prescription of sinus rhythm maintenance therapy for patients treated for atrial fibrillation: a secondary analysis of the HERMES-AF study

Fernández-Simón A, Martín A, Suero C, Sánchez J, Varona M, Sánchez S, Cancio M, Carbajosa J, Tamargo J, Del Arco C, Medrano FJ, Coll-Vinent B

Grupo de Arritmias Cardiacas y Síncope, Sociedad Española de Medicina de Urgencias y Emergencias. Servicio de Urgencias, Hospital Universitario Virgen del Rocío, Sevilla, Spain. Servicio de Urgencias, Hospital Universitario de Móstoles, Madrid, Spain. Área de Cuidados Críticos y Urgencias, Hospital de La Axarquía, Málaga, Spain. Servicio de Urgencias, Hospital Universitario Virgen de las Nieves, Granada, Spain. Servicio de Urgencias, Hospital de Basurto, Bilbao, Spain. Servicio de Urgencias, Hospital Universitario Río Hortega, Valladolid, Spain. Servicio de Urgencias, Hospital Donostia, San Sebastián, Spain. Servicio de Urgencias, Hospital General Universitario de Alicante, Spain. Departamento de Farmacología, CIBERCV, Universidad Complutense, Madrid, Spain. Servicio de Urgencias, Hospital Universitario de la Princesa, Madrid, Spain. Servicio de Medicina Interna, Hospital Universitario Virgen del Rocío, CIBERESP, Sevilla, Spain. Área de Urgencias, Grup de Recerca “Urgències: processos i patologies”. IDIBAPS. Unitat de Fibrillació Auricular (UFA). Hospital Clínic. Barcelona, Spain.

Background and objective. The maintenance of sinus rhythm by means of antiarrhythmic drugs and/or upstream therapy to counter cardiac remodeling is fundamental to the management of atrial fibrillation (AF). This study aimed to analyze this approach and its appropriateness in the setting of hospital emergency departments.
Methods. Secondary analysis of data from the multicenter observational cross-sectional HERMES-AF study carried out in 124 hospitals representative of the Spanish national health service in 2011. Included were consecutive patients with AF restored to sinus rhythm who were discharged home from emergency care.
Results. A total of 449 patients were included; 204 (45.4%) were already on sinus rhythm maintenance therapy. Of the 245 remaining patients, 107 (43.67%) were prescribed maintenance treatment in the emergency department, as follows: 41, an antiarrhythmic drug; 19, upstream therapy; and 49, both treatments. The selection of an
antiarrhythmic drug did not follow guideline recommendations in 10 patients (11.8%). Antiarrhythmic drug prescription was associated with having had a prior episode of AF (odds ratio [OR], 2.024; 95% CI, 1.196-3.424; P = .009); a heart rate of more than 110 beats/min (OR, 2.147; 95% CI, 1.034-4.456, P = 0.40); and prescription of
anticoagulation on discharge (OR, 1.862; 95% CI, 1.094-3.170; P = .022). Upstream therapy prescription was associated only with a heart rate over 110 beats/min (OR, 2.187; 95% CI, 1.005-4.757; P = .018). In total, 311 patients (69.23%) were discharged from the emergency department with sinus rhythm maintenance therapy: 87 with an antiarrhythmic drug, 117 with an upstream therapy, and 107 with both.
Conclusions. Treatment to prevent the recurrence of AF is underprescribed in emergency departments. Increasing such prescription and ensuring the appropriateness of antiarrhythmic therapy prescribed are points emergency departments can improve in the interest of better sinus rhythm maintenance.

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