INTRODUCTION:International rates of hospitalization for atrial fibrillation and flutter (AFF) from the emergency department (ED) vary widely without clear evidence to guide the identification of high-risk patients requiring inpatient management. We sought to determine (1) variation in hospital admission and (2) modifiable factors associated with hospitalization of AFF patients within a U.S. integrated health system. METHODS:This multicenter prospective observational study of health plan members with symptomatic AFF was conducted using convenience sampling in 7 urban community EDs from 05/2011 to 08/2012. Prospective data collection included presenting symptoms, characteristics of atrial dysrhythmia, ED physician impression of hemodynamic instability, comorbid diagnoses, ED management, and ED discharge rhythm. All centers had full-time on-call cardiology consultation available. Additional variables were extracted from the electronic health record. We identified factors associated with hospitalization and included predictors in a multivariate Poisson Generalized Estimating Equations regression model to estimate adjusted relative risks while accounting for clustering by physician. RESULTS:Among 1,942 eligible AFF patients, 1,074 (55.3%) were discharged home and 868 (44.7%) were hospitalized. Hospitalization rates ranged from 37.4% to 60.4% across medical centers. After adjustment, modifiable factors associated with increased hospital admission from the ED included non-sinus rhythm at ED discharge, no attempted cardioversion, and heart rate reduction. DISCUSSION:Within an integrated health system, we found significant variation in AFF hospitalization rates and identified several modifiable factors associated with hospital admission. Standardizing treatment goals that specifically address best practices for ED rate reduction and rhythm control may reduce hospitalizations.

Ibutilide is recommended by professional society guidelines for the cardioversion of atrial fibrillation and flutter.1,2 Its rapid effect and minimal impact on hemodynamics make it well suited for use in the Emergency Department (ED).3 Ibutilide, however, prolongs the corrected QT (QTc) interval and increases risk for ventricular tachycardia (VT).4–6 The risk of VT can be greatly mitigated by careful selection of low-risk patients, the optimal dose of prophylactic magnesium sulfate, and at least 4 hours of postibutilide electrocardiographic monitoring.3 This case illustrates the dangers of overlooking ibutilide contraindications and provides practical lessons in ibutilide use and management of ibutilide-induced VT.

Objective: Acute pulmonary embolism (aPE) is a fatal condition that can lead to death if not quickly identified. The gold standard for the evaluation of aPE includes a Computed Tomography scan of the Pulmonary Arteries (CTPA). Despite the accuracy of CTPA, many patients are unable to undergo this test due to renal disease, pregnancy, or risk of radiation. Ultrasonography has shown some promise in obtaining the tricuspid annular plane systolic excursion (TAPSE) measurements to help diagnose patients with aPE. Our goal is to asses if TAPSE measurements are an effective mechanism in assessing patients with a suspicion of aPE. Methods: We prospectively enrolled patients who presented to the Emergency Department with a clinical suspicion of aPE. Each patient underwent a point of care ultrasound (POCUS) to obtain a TAPSE measurement, followed by a CTPA scan. This study consists of a comparative analysis of three cohorts of patients based on the results from CTPA scan. The three groups consisted of pateints with no PE, clinically insignificant PE, and clinically significant PE. Results: A total of 87 patients were enrolled in this study. Of these patients, 12 were found to have clinically significant aPE, 10 were found to have clinically insignificant PE, and 65 were found to not have a PE. Of the patients with clinically significant aPE, 58.3% were found to have TAPSE value less than 16mm. Comparatively, of the patients with clinically insignificant PE or no PE, only 10% and 3% of patients were found to have TAPSE values less than 16mm respectively. The average TAPSE values for patients with clinically significant aPE (15.2 mm) was significantly different when compared to the clinically insignificant aPE (22.2 mm) and no aPE (22.8 mm) groups. Conclusion: There was no significant difference in TAPSE measurements between the no PE and clinically insignificant PE, however a significant difference exists between all three groups. This data suggests that emergency physicians can use POCUS to aid in the diagnosis of patients with aPE through TAPSE measurements.