Emergency Department Pathways
Canadian Cardiovascular Society (CSC): The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation (Andrade et al, Can J Cardiol [CJC] 2020 and SUPPL)
The Canadian Cardiovascular Society, in collaboration with the Canadian Heart Rhythm Society, provides comprehensive evidence-based recommendations for the use of vitamin K antagonists and direct oral anticoagulants (DOACs) in patients with nonvalvular atrial fibrillation (NVAF), including those with chronic kidney disease (CKD), end-stage renal disease (ESRD), coronary artery disease, liver disease, advanced age, frailty, or increased body mass index (BMI), and in those undergoing cardioversion, catheter ablation, or other invasive procedures. The guidelines also provide recommendations on the prevention and management of DOAC-associated bleeding events. Several clinical pathways to help guide anticoagulation therapy decision-making in various clinical scenarios are provided.
Identification and Early Anticoagulation in Patients With Atrial Fibrillation in the Emergency Department (Schwab et al, Am J Emerg Med 2020)
This article describes the results of a transition-of-care protocol that was developed to improve guideline-based oral anticoagulant management in the emergency department of a medical center located in an underserved San Diego community. The article also describes treatment gaps in prescribing oral anticoagulants for patients with nonvalvular atrial fibrillation at risk for stroke in the emergency department.
The Canadian Community Utilization of Stroke Prevention Study in Atrial Fibrillation in the Emergency Department (C-CUSP ED) (Parkash et al, Ann Emerg Med 2019)
This article describes the design and implementation of a toolkit to guide initiation of oral anticoagulation in patients with atrial fibrillation in 5 emergency departments (EDs) in Canada.
Canadian Cardiovascular Society (CCS): Society Guidelines: 2018 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation (Andrade et al, Can J Cardiol [CJC] 2018 and SUPPL)
This updated guidance, published by the EHRA in 2018, provides evidence-based recommendations for the use of direct oral anticoagulants (DOACs) in patients with nonvalvular atrial fibrillation (NVAF), including eligibility assessment; monitoring; transitioning between vitamin K antagonists and DOACs; possible drug-drug interactions (DDIs); dosing adjustments in the elderly, in patients with hepatic or renal impairment, or based on body weight; management of DOAC-associated bleeding (including use of reversal agents); and periprocedural management considerations for elective or emergency procedures (including ablation and cardioversion). Sample pathways to help guide decision making are included for various clinical scenarios.
Acute Management of Atrial Fibrillation: From Emergency Department to Cardiac Care Unit (Atzema and Singh, Cardiol Clin 2018)
In this narrative review, the authors outline initial management strategies for patients presenting to the ED with AF, including options for rate and rhythm control and anticoagulation.
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American College of Emergency Physicians (ACEP): Creation and Implementation of an Outpatient Pathway for Atrial Fibrillation in the Emergency Department Setting: Results of an Expert Panel (Baugh et al, Acad Emerg Med [AEM] 2018)
An expert panel of 14 emergency physicians, cardiologists, and other multidisciplinary team members from the United States and Canada developed an outpatient pathway for ED physicians to assess and treat patients with AF.
Tampa General Hospital (FL): Atrial Fibrillation Clinical Decision Aid for Emergency Medicine Providers: An Initiative to Improve Quality Healthcare Outcomes in Adults With New-Onset Atrial Fibrillation (Cardy et al, Heart Lung 2018)
This article describes institution of a clinical pathway for new-onset AF at a single emergency department (ED).
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DC Cardioversion of Atrial Fibrillation and Atrial Flutter in the Emergency Department: Improving Specialist Protocols for the Generalist (Carpenter and Sargent, BMJ Open Qual 2018)
This article describes the process used by the Departments of Cardiology and Emergency Medicine at Severn Deanery, Bristol, UK, to design a multimodality educational program and new treatment protocol, including periprocedural anticoagulation, in patients with recent-onset atrial fibrillation undergoing direct current cardioversion in the emergency department.
St. Joseph Mercy Hospital (MI): Implementation of a Novel Algorithm to Decrease Unnecessary Hospitalizations in Patients Presenting to a Community Emergency Department With Atrial Fibrillation (DeMeester et al, Acad Emerg Med [AEM] 2018)
This article describes implementation of a clinical pathway to identify and treat low-risk patients with AF in the ED of a community hospital in Michigan.
Emergency Medicine Considerations in Atrial Fibrillation (Long et al, Am J Emerg Med [AJEM] 2018)
This review describes emergency department (ED) considerations in the management of AF, with an emphasis on patient evaluation, rate and rhythm control, cardioversion, anticoagulation, and patient disposition.
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Canadian Association of Emergency Physicians (CAEP): CAEP Position Statement. CAEP Acute Atrial Fibrillation/Flutter Best Practices Checklist (Stiell et al, CJEM 2018)
Recommended by the CAEP, this checklist was created to assist emergency department (ED) physicians in managing symptomatic patients who present with acute or recent-onset AF. The checklist is an adaptation of clinical practice guidelines developed by the Canadian Cardiovascular Society (CCS) for use by ED physicians. A sample pathway, along with detailed information on risk assessment, rate and rhythm control, options for short-term and long-term reduction of stroke risk in patients with AF , and follow-up are included.
University of British Columbia Hospitals: Implementation of an Emergency Department Atrial Fibrillation and Flutter Pathway Improves Rates of Appropriate Anticoagulation, Reduces Length of Stay and Thirty-Day Revisit Rates for Congestive Heart Failure (Barbic et al, CJEM 2017 and SUPPL)
This article describes implementation of an evidence-based AF clinical pathway in the EDs of St. Paul’s Hospital and Mount St. Joseph Hospital at the University of British Columbia in Canada, dosing considerations based on age, body weight, drug-drug interactions (DDIs), and renal impairment, and recommendations for outpatient follow-up.
Mount Sinai St Luke’s Hospital (NY): Pathway for the Management of Atrial Fibrillation and Atrial Flutter (Herzog et al, Crit Pathw Cardiol 2017)
Mount Sinai St Luke’s Hospital in New York, NY, developed a pathway for the initial assessment and management of AF and atrial flutter that includes options for rate control, anticoagulation, cardioversion, and electrophysiology/antiarrhythmic medication, which they designated the RACE pathway.
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Massachusetts General Hospital: Effect of a Multidisciplinary Approach for the Management of Patients With Atrial Fibrillation in the Emergency Department on Hospital Admission Rate and Length of Stay (Ptaszek et al, Am J Cardiol [AJC] 2016)
The treatment pathway for evaluation and management of AF in the ED, codeveloped by physicians from the cardiac electrophysiology service and the department of Emergency Medicine at Massachusetts General Hospital, is outlined in this article.
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