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Variation in practice patterns among specialties in the acute management of atrial fibrillation.

Funk AM, Kocher KE, Rohde JM, West BT, Crawford TC, Froehlich JB, Saberi S - BMC Cardiovasc Disord (2015)

Bottom Line: Australasian physicians were more aggressive with rhythm control for paroxysmal AF with low CHADS2 score compared to US physicians.Significant variation exists among specialties in the management of acute AF, likely reflecting a lack of high quality research to direct the provider.Future studies may help to standardize practice leading to decreased rates of hospitalization and overall cost.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan School of Medicine, Ann Arbor, USA. amaire@med.umich.edu.

ABSTRACT

Background: Atrial fibrillation (AF) is commonly managed by a variety of specialists. Current guidelines differ in their recommendations leading to uncertainty regarding important clinical decisions. We sought to document practice pattern variation among cardiologists, emergency physicians (EP) and hospitalists at a single academic, tertiary-care center.

Methods: A survey was created containing seven clinical scenarios of patients presenting with AF. We analyzed respondent choices regarding rate vs rhythm control, thromboembolic treatment and hospitalization strategies. Finally, we contrasted our findings with a comparable Australasian survey to provide an international reference.

Results: There was a 78% response rate (124 of 158), 37% hospitalists, 31.5% cardiologists, and 31.5% EP. Most respondents chose rate over rhythm control (92.2%; 95% CI, 89.1% - 94.5%) and thromboembolic treatment (67.8%; 95% CI, 63.8% - 71.7%). Compared to both hospitalists and EPs, cardiologists were more likely to choose thromboembolic treatment for new and paroxysmal AF (adjusted OR 2.38; 95% CI, 1.05 - 5.41). They were less likely to favor hospital admission across all types of AF (adjusted OR 0.36; 95% CI, 0.17 - 0.79) but thought cardiology consultation was more important (adjusted OR 1.88, 95% CI, 0.97 - 3.64). Australasian physicians were more aggressive with rhythm control for paroxysmal AF with low CHADS2 score compared to US physicians.

Conclusions: Significant variation exists among specialties in the management of acute AF, likely reflecting a lack of high quality research to direct the provider. Future studies may help to standardize practice leading to decreased rates of hospitalization and overall cost.

No MeSH data available.


Related in: MedlinePlus

Thromboembolic treatment. Bar graph depicting the percentage of each specialty choosing thromboembolic treatment and the percentage that chose bridging in the acute management of AF across scenarios 1–5. There was a significant difference between specialties regarding the decision to use thromboembolic treatment, p = 0.014 as well as the decision to bridge, p < 0.001. NOTE: Abbreviation: AF, atrial fibrillation.
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Fig2: Thromboembolic treatment. Bar graph depicting the percentage of each specialty choosing thromboembolic treatment and the percentage that chose bridging in the acute management of AF across scenarios 1–5. There was a significant difference between specialties regarding the decision to use thromboembolic treatment, p = 0.014 as well as the decision to bridge, p < 0.001. NOTE: Abbreviation: AF, atrial fibrillation.

Mentions: Most respondents chose thromboembolic treatment across all scenarios (67.8%; 95% CI 63.8% to 71.7%), though with significant differences among specialties regarding the decision (Figure 2). Cardiologists were more likely to do so in new and paroxysmal AF scenarios than either of the other specialists (OR 2.38, 95% CI 1.05 to 5.41). They were also more likely to choose transesophageal echocardiogram (78.8% vs 69.5% of hospitalists and 57.6% of EPs, p = 0.01) and use antithrombotics (90.4% vs 87.4% of hospitalists and 7.2% of EPs, p < 0.001) prior to cardioversion. In multivariable modeling, the adjusted odds of choosing thromboembolic treatment were higher with a high CHADS2 score (OR 6.89; 95% CI 3.79 to 12.56). A low CHADS2 score and duration of AF < 48 hours predicted a lower odds of bridging (defined as administration of short-acting heparin for antithrombosis until warfarin levels become therapeutic) (OR 0.34, 95% CI 0.17 to 0.68 and OR 0.59, 95% CI 0.39 to 0.91). Most (60%) of those choosing thromboembolic treatment selected a regimen of heparin with subsequent warfarin. EPs used heparin without subsequent long-term anticoagulation the most and avoided newer generation anticoagulants such as dabigatran and rivaroxaban (agents available at the time of the survey distribution) altogether. Hospitalists were more likely than EPs or cardiologists to use warfarin or aspirin alone (36.5%, 9.6%, and 12.9%, respectively). In multivariable modeling, cardiologists and EPs had 4 times higher odds of choosing to bridge than hospitalists (OR 4.02, 95% CI 1.67 to 9.65).Figure 2


Variation in practice patterns among specialties in the acute management of atrial fibrillation.

Funk AM, Kocher KE, Rohde JM, West BT, Crawford TC, Froehlich JB, Saberi S - BMC Cardiovasc Disord (2015)

Thromboembolic treatment. Bar graph depicting the percentage of each specialty choosing thromboembolic treatment and the percentage that chose bridging in the acute management of AF across scenarios 1–5. There was a significant difference between specialties regarding the decision to use thromboembolic treatment, p = 0.014 as well as the decision to bridge, p < 0.001. NOTE: Abbreviation: AF, atrial fibrillation.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4359491&req=5

Fig2: Thromboembolic treatment. Bar graph depicting the percentage of each specialty choosing thromboembolic treatment and the percentage that chose bridging in the acute management of AF across scenarios 1–5. There was a significant difference between specialties regarding the decision to use thromboembolic treatment, p = 0.014 as well as the decision to bridge, p < 0.001. NOTE: Abbreviation: AF, atrial fibrillation.
Mentions: Most respondents chose thromboembolic treatment across all scenarios (67.8%; 95% CI 63.8% to 71.7%), though with significant differences among specialties regarding the decision (Figure 2). Cardiologists were more likely to do so in new and paroxysmal AF scenarios than either of the other specialists (OR 2.38, 95% CI 1.05 to 5.41). They were also more likely to choose transesophageal echocardiogram (78.8% vs 69.5% of hospitalists and 57.6% of EPs, p = 0.01) and use antithrombotics (90.4% vs 87.4% of hospitalists and 7.2% of EPs, p < 0.001) prior to cardioversion. In multivariable modeling, the adjusted odds of choosing thromboembolic treatment were higher with a high CHADS2 score (OR 6.89; 95% CI 3.79 to 12.56). A low CHADS2 score and duration of AF < 48 hours predicted a lower odds of bridging (defined as administration of short-acting heparin for antithrombosis until warfarin levels become therapeutic) (OR 0.34, 95% CI 0.17 to 0.68 and OR 0.59, 95% CI 0.39 to 0.91). Most (60%) of those choosing thromboembolic treatment selected a regimen of heparin with subsequent warfarin. EPs used heparin without subsequent long-term anticoagulation the most and avoided newer generation anticoagulants such as dabigatran and rivaroxaban (agents available at the time of the survey distribution) altogether. Hospitalists were more likely than EPs or cardiologists to use warfarin or aspirin alone (36.5%, 9.6%, and 12.9%, respectively). In multivariable modeling, cardiologists and EPs had 4 times higher odds of choosing to bridge than hospitalists (OR 4.02, 95% CI 1.67 to 9.65).Figure 2

Bottom Line: Australasian physicians were more aggressive with rhythm control for paroxysmal AF with low CHADS2 score compared to US physicians.Significant variation exists among specialties in the management of acute AF, likely reflecting a lack of high quality research to direct the provider.Future studies may help to standardize practice leading to decreased rates of hospitalization and overall cost.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan School of Medicine, Ann Arbor, USA. amaire@med.umich.edu.

ABSTRACT

Background: Atrial fibrillation (AF) is commonly managed by a variety of specialists. Current guidelines differ in their recommendations leading to uncertainty regarding important clinical decisions. We sought to document practice pattern variation among cardiologists, emergency physicians (EP) and hospitalists at a single academic, tertiary-care center.

Methods: A survey was created containing seven clinical scenarios of patients presenting with AF. We analyzed respondent choices regarding rate vs rhythm control, thromboembolic treatment and hospitalization strategies. Finally, we contrasted our findings with a comparable Australasian survey to provide an international reference.

Results: There was a 78% response rate (124 of 158), 37% hospitalists, 31.5% cardiologists, and 31.5% EP. Most respondents chose rate over rhythm control (92.2%; 95% CI, 89.1% - 94.5%) and thromboembolic treatment (67.8%; 95% CI, 63.8% - 71.7%). Compared to both hospitalists and EPs, cardiologists were more likely to choose thromboembolic treatment for new and paroxysmal AF (adjusted OR 2.38; 95% CI, 1.05 - 5.41). They were less likely to favor hospital admission across all types of AF (adjusted OR 0.36; 95% CI, 0.17 - 0.79) but thought cardiology consultation was more important (adjusted OR 1.88, 95% CI, 0.97 - 3.64). Australasian physicians were more aggressive with rhythm control for paroxysmal AF with low CHADS2 score compared to US physicians.

Conclusions: Significant variation exists among specialties in the management of acute AF, likely reflecting a lack of high quality research to direct the provider. Future studies may help to standardize practice leading to decreased rates of hospitalization and overall cost.

No MeSH data available.


Related in: MedlinePlus