Clare L Atzema1, Paul Dorian2, Jiming Fang3, Jack V Tu4, Douglas S Lee5, Alice S Chong3, Peter C Austin6. 1. Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Division of Emergency Medicine, the Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. Electronic address: clare.atzema@ices.on.ca. 2. Cardiology, the Department of Medicine, University of Toronto, Toronto, Ontario, Canada; St Michael's Hospital, Toronto, Ontario, Canada. 3. Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada. 4. Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Internal Medicine, the Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation at the University of Toronto, Toronto, Ontario, Canada. 5. Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Cardiology, the Department of Medicine, University of Toronto, Toronto, Ontario, Canada; University Health Network, Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation at the University of Toronto, Toronto, Ontario, Canada. 6. Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation at the University of Toronto, Toronto, Ontario, Canada.
Abstract
STUDY OBJECTIVE: The high volume of patients treated in an emergency department (ED) for atrial fibrillation is predicted to increase significantly in the next few decades. Currently, 11% of these patients die within a year. We sought to derive and validate a complex model and a simplified model that predicts mortality in ED patients with atrial fibrillation. METHODS: This population-based, retrospective cohort study included 3,510 adult patients with a primary diagnosis of atrial fibrillation who were treated at 24 hospital EDs in Ontario, Canada, between April 2008 and March 2009. The main outcome was 30-day all-cause mortality. RESULTS: In the derivation cohort (n=2,343; mean age 68.8 years), 2.6% of patients died within 30 days of the ED visit versus 2.7% in the validation cohort (n=1,167; mean age 68.3 years). Variables associated with mortality in the complex model included age, presenting pulse rate and systolic blood pressure, presence of chest pain, 2 laboratory results (positive troponin result and creatinine level greater than 200 μmol [2.26 mg/dL]), 4 comorbidities (smoking, chronic obstructive pulmonary disease, cancer, and dementia), an increased bleeding risk, and a second acute ED diagnosis (in addition to atrial fibrillation). Observed 30-day mortality in the 5 risk strata that were defined by the predicted probability of death were 0.44%, 0.41%, 0.23%, 1.61%, and 10.3%. The c statistics were 0.88 and 0.87 in the derivation and validation cohorts, respectively. The a priori-selected 6-variable model, TrOPs-BAC, included a positive Troponin result, Other acute ED diagnosis, Pulmonary disease (chronic obstructive pulmonary disease), Bleeding risk, Aged 75 years or older, and Congestive heart failure. The c statistic for the simplified model was 0.81 in both the derivation and validation cohorts. CONCLUSION: Using a population-based sample, we derived and validated both a complex and a simplified instrument that predicts mortality after an emergency visit for atrial fibrillation. These may aid clinicians in identifying high-risk patients for hospitalization while safely discharging more patients home.
STUDY OBJECTIVE: The high volume of patients treated in an emergency department (ED) for atrial fibrillation is predicted to increase significantly in the next few decades. Currently, 11% of these patients die within a year. We sought to derive and validate a complex model and a simplified model that predicts mortality in ED patients with atrial fibrillation. METHODS: This population-based, retrospective cohort study included 3,510 adult patients with a primary diagnosis of atrial fibrillation who were treated at 24 hospital EDs in Ontario, Canada, between April 2008 and March 2009. The main outcome was 30-day all-cause mortality. RESULTS: In the derivation cohort (n=2,343; mean age 68.8 years), 2.6% of patients died within 30 days of the ED visit versus 2.7% in the validation cohort (n=1,167; mean age 68.3 years). Variables associated with mortality in the complex model included age, presenting pulse rate and systolic blood pressure, presence of chest pain, 2 laboratory results (positive troponin result and creatinine level greater than 200 μmol [2.26 mg/dL]), 4 comorbidities (smoking, chronic obstructive pulmonary disease, cancer, and dementia), an increased bleeding risk, and a second acute ED diagnosis (in addition to atrial fibrillation). Observed 30-day mortality in the 5 risk strata that were defined by the predicted probability of death were 0.44%, 0.41%, 0.23%, 1.61%, and 10.3%. The c statistics were 0.88 and 0.87 in the derivation and validation cohorts, respectively. The a priori-selected 6-variable model, TrOPs-BAC, included a positive Troponin result, Other acute ED diagnosis, Pulmonary disease (chronic obstructive pulmonary disease), Bleeding risk, Aged 75 years or older, and Congestive heart failure. The c statistic for the simplified model was 0.81 in both the derivation and validation cohorts. CONCLUSION: Using a population-based sample, we derived and validated both a complex and a simplified instrument that predicts mortality after an emergency visit for atrial fibrillation. These may aid clinicians in identifying high-risk patients for hospitalization while safely discharging more patients home.
Authors: Clare L Atzema; Cynthia A Jackevicius; Alice Chong; Paul Dorian; Noah M Ivers; Ratika Parkash; Peter C Austin Journal: CMAJ Date: 2019-12-09 Impact factor: 8.262
Authors: Bory Kea; E Margaret Warton; Dustin W Ballard; Dustin G Mark; Mary E Reed; Adina S Rauchwerger; Steven R Offerman; Uli K Chettipally; Patricia C Ramos; Daphne D Le; David S Glaser; David R Vinson Journal: J Atr Fibrillation Date: 2021-02-28