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Article

Active management of atrial fibrillation or flutter in emergency department patients with renal impairment is associated with a higher risk of adverse events and treatment failure

  • Frank X. Scheuermeyer (a1), Hubert Wong (a2), Tyler W. Barrett (a3), Jim Christenson (a1), Eric Grafstein (a1), Brian Grunau (a1) (a2), Matt Wiens (a1) and Grant Innes (a4)...
Abstract
CLINICIAN'S CAPSULE

What is known about the topic?

The influence of renal impairment upon emergency department-based outcomes in patients with atrial fibrillation or flutter (AFF) is unknown.

What did this study ask?

What was the impact of renal impairment upon adverse events (AE) and rate and rhythm control (RRC) attempts in emergency department (ED) AFF patients?

What did this study find?

When ED AFF patients with renal impairment are administered RRC, they have more than 10% excess AE risk.

Why does this study matter to clinicians?

Emergency physicians should be cautious about attempting RRC in ED AFF patients with renal impairment.

Contexte

La fibrillation auriculaire et le flutter auriculaire (FFA) chez les patients atteints d'un dysfonctionnement rénal comportent un pronostic sombre à long terme, mais la documentation reste silencieuse sur leur prise en charge au service des urgences (SU). L’étude avait donc pour objet l'incidence du dysfonctionnement rénal sur les résultats cliniques après une réduction de la fréquence (RF) cardiaque ou une régularisation du rythme (RR) cardiaque, dont la survenue d’événements indésirables (EI) au SU ou l’échec du traitement.

Méthode

Il s'agit d'une étude de cohorte qui visait à repérer des patients consécutifs atteints de FFA, à l'aide de données sur les ECG recueillies dans deux grands centres urbains, et à examiner les dossiers médicaux à la recherche de renseignements sur les affections concomitantes; la prise en charge au SU, dont les traitements par RF/RR; les EI prédéterminés et l’échec du traitement. Les patients ont été divisés en deux groupes : fonctionnement rénal normal (débit de filtration glomérulaire estimé [DFGe] ≥ 60 ml/min/1,73 m2) et fonctionnement rénal anormal (DFGe faible). Les critères principal et secondaire d’évaluation comprenaient des EI prédéterminés et l’échec du traitement, respectivement. Ont été calculés 1) le risque excédentaire rajusté d'EI chez les patients atteints d'un dysfonctionnement rénal qui ont été soumis à une RF/RR; et 2) le risque relatif approché [RRA] rajusté d’échec du traitement par RF/RR.

Résultats

Sur 1112 patients consécutifs examinés pour FFA au SU, 412 (37,0%) avaient un faible DFGe. Le taux brut d'EI après une RF/RR était de 27/238 (11,3%) chez les patients ayant un fonctionnement rénal normal et de 26/103 (25,2%) chez les patients ayant un faible DFGe. Parmi ceux qui ont été soumis à une RF/RR dans ce dernier groupe, le risque excédentaire rajusté d'EI s'est établi à 13,7% (IC à 95% : 1,7-25,1%) et le RRA rajusté d'ET par RF/RR, à 3,07 (IC à 95% : 1,74-5,43).

Conclusion

Dans cette cohorte composée de patients atteints de FFA et traités par RF/RR au SU, ceux qui avaient un faible DFGe ont connu une augmentation importante du risque excédentaire rajusté d'EI comparativement aux patients qui avaient un fonctionnement rénal normal. Il en allait de même pour le RRA d’échec du traitement.

Copyright
COPYRIGHT: © Canadian Association of Emergency Physicians 2019 
Corresponding author
Correspondence to: Frank X. Scheuermeyer, Department of Emergency Medicine, St Paul's Hospital and the University of British Columbia, 1081 Burrard St, Vancouver, BC, Canada V6Z 1Y6; Email: frank.scheuermeyer@gmail.com
References
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1.McDonald, AJ, Pelletier, AJ, Ellinor, PT, et al. Increasing US emergency department visit rates and subsequent hospital admissions for atrial fibrillation from 1993 to 2004. Ann Emerg Med 2008;51:58-65.
2.Connolly, S, Gillis, A. 2004 CCS Consensus Conference on Atrial Fibrillation. Therapies for the prevention of stroke and other vascular events in atrial fibrillation and flutter. Can J Cardiol 2005;21(Suppl B):71B-3B.
3.Heilbron, B, Klein, GJ, Talajic, M, et al. 2004 CCS Consensus Conference on Atrial Fibrillation. Management of atrial fibrillation in the emergency department and following acute myocardial infarction. Can J Cardiol 2005;(21 Suppl B)71B-3B.
4.Stiell, IG, Scheuermeyer, FX, Vadeboncouer, A, et al. CAEP acute atrial fibrillation/flutter best practices checklist. CJEM 2018;20(3):334-342.
5.Cairns, JA, Connolly, SJ, McMurtry, S, et al. Canadian Cardiovascular Society atrial fibrillation guidelines 2010: prevention of stroke and systemic thromboembolism in atrial fibrillation and flutter. Can J Cardiol 2011;27:74-90.
6.Fuster, V, Ryden, LE, Cannom, DS, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation. Circulation 2006;114:700-52.
7.Wann, LS, Curtis, AB, January, CT. 2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (updating the 2006 guideline). J Am Coll Cardiol 2011;57:223-42.
8.Skanes, AC, Healy, JS, Cairns, JA, et al. Focused 2012 update of the Canadian Cardiovascular Society Atrial Fibrillation Guidelines: recommendations for stroke prevention and rate/rhythm control. Can J Cardiol 2012;28:125-36.
9.Atzema, CL, Lam, K, Young, C, et al. Patients with atrial fibrillation and an alternative primary diagnosis in the emergency department: a description of their characteristics and outcomes. Acad Emerg Med 2013;20:193-200.
10.Scheuermeyer, FX, Pourvali, R, Rowe, BH, et al. Emergency department patients with atrial fibrillation or flutter and an acute underlying medical illness may not benefit from attempts to control rate or rhythm. Ann Emerg Med 2015;65:511-22.e2.
11.Nakagawa, K, Hirai, T, Takashima, S, et al. Chronic kidney disease and CHADS 2 score independently predict cardiovascular events and mortality in patients with nonvalvular atrial fibrillation. Am J Cardiol 2011;107:912-6.
12.Piccini, JP, Stevens, SR, Chang, Y, et al. Renal dysfunction as a predictor of stroke and systemic embolism in patients with nonvalvular atrial fibrillation: validation of the R2CHADS2 index in the ROCKET-AF and ATRIA study cohorts. Circulation 2013;127:224-32.
13.Andersson, T, Magnuson, A, Bryngelsson, IL, et al. All-cause mortality in 272 186 patients hospitalized with incident atrial fibrillation 1995–2008: a Swedish nationwide long-term case-control study. Eur Heart J 2013;34(14):1061-7.
14.Fox, KA, Piccini, JP, Wojdyla, D, et al. Prevention of stroke and systemic embolism with rivaroxaban compared with warfarin in patients with non-valvular atrial fibrillation and moderate renal impairment. Eur Heart J 2011;32:2387-94.
15.Oleson, JB, Kip, GY, Kamper, AL, et al. Stroke and bleeding in atrial fibrillation with chronic kidney disease. NEJM 2012;367:625-35.
16.Atzema, CL, Lam, K, Young, C, Kester-Greene, N. Patients with atrial fibrillation and an alternative primary diagnosis in the emergency department. A description of their characteristics and outcomes. Acad Emerg Med 2013;20:193-9.
17.Scheuermeyer, FX, Grafstein, E, Stenstrom, R, et al. Thirty day and one-year outcomes of emergency department patients with atrial fibrillation and no acute underlying medical cause. Ann Emerg Med 2012;60:755-62.e2.
18.Scheuermeyer, FX, Grafstein, E, Stenstrom, R, et al. Safety and efficiency of calcium channel blockers versus beta-blockers for rate control in patients with atrial fibrillation and no acute underlying medical illness. Acad Emerg Med 2013;20:222-30.
19.Levey, AS, Bosch, JP, Lewis, JB, et al. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med 1999;130:461-70.
20.Gilbert, EH, Lowenstein, SR, Koziol-McLain, J, et al. Chart reviews in emergency medicine research: where are the methods? Ann Emerg Med 1996;27:305-8.
21.Worster, A, Bledsoe, RD, Cleve, P, et al. Reassessing the methods of medical record review studies in emergency medicine research. Ann Emerg Med 2005;45:448-51.
22.Gage, BF, Waterman, AD, Shannon, C, et al. Validation of clinical classification schemes for predicting stroke. Results from the National Registry of Atrial Fibrillation. JAMA 2001;285:2864-70.
23.Levey, AS, Becker, C, Inker, LA. Glomerular filtration rate and albuminuria for detection and staging of acute and chronic kidney disease in adults. JAMA 2015;313:834-46.
24.Chronic kidney disease: early identification and management of chronic kidney disease in adults in primary and secondary care; 2013. Available at: http://www.kdigo.org/clinical_practice_guidelines/pdf/CKD/KDIGO_2012_CKD_GL.pdf (accessed May 1, 2018).
25.Lassnigg, A, Schmidlin, D, Mouhieddine, M, et al. Minimal changes of serum creatinine predict prognosis in patients after cardiothoracic surgery: a prospective cohort study. J Am Soc Nephrol 2004;15:1597-1605.
26.Greenslade, JH, Cullen, L, Kalinowski, L, et al. Examining renal impairment as a risk factor for acute coronary syndrome. A prospective observational study. Ann Emerg Med 2013;62:38-46.e1.
27.Villar, J, Clement, JP, Stotts, J, et al. Many emergency department patients with severe sepsis and septic shock do not meet diagnostic criteria within three hours of arrival. Ann Emerg Med 2014;64:48-54.
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