scholarly journals Care and referral patterns in a large, dedicated nurse-led atrial fibrillation outpatient clinic

2021 ◽  
Author(s):  
F. R. Piersma ◽  
J. Neefs ◽  
W. R. Berger ◽  
N. W. E. van den Berg ◽  
R. Wesselink ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Outpatient Clinic ◽  
Patient Characteristics ◽  
Initial Assessment ◽  
Cardiac Work ◽  
Referral Patterns ◽  
System A ◽  
Cardiac Assessment ◽  
Work Up

Abstract Introduction Atrial fibrillation (AF) is the most common arrhythmia and imposes a high burden on the healthcare system. A nurse-led AF outpatient clinic may alleviate the burden on the cardiology outpatient clinic by triaging patients who need care by a cardiologist or general practitioner (GP). However, care and referral patterns after initial assessment in a nurse-led AF outpatient clinic are unknown. We examined the proportion of AF patients assessed in a nurse-led clinic without outpatient follow-up by a cardiologist. Methods All patients with AF referred to our tertiary medical centre underwent cardiac work-up in the nurse-led AF outpatient clinic and were prospectively followed. Data on patient characteristics, rhythm monitoring and echocardiography were collected and described. Odds ratio (OR) for continuing care in the nurse-led AF outpatient clinic was calculated. Results From 2014 to 2018, 478 consecutive individual patients were referred to the nurse-led AF outpatient clinic. After the initial cardiac work-up, 139 patients (29.1%) remained under nurse-led care and 121 (25.3%) were referred to a cardiologist and 218 (45.6%) to a GP. Patients who remained under nurse-led care were significantly younger, were more symptomatic, more often had paroxysmal AF and had less comorbidities than the other two groups. After multivariable testing, CHA2DS2-VASc score ≥ 2 was associated with discontinued nurse-led care (OR 0.57, 95% confidence interval 0.34–0.95). Conclusion After initial cardiac assessment in the nurse-led outpatient clinic, about half of the newly referred AF patients were referred back to their GP. This strategy may reduce the burden of AF patients on secondary or tertiary cardiology outpatient clinics.

scholarly journals Radiofrequency versus Cryoballoon Ablation of Atrial Fibrillation: An Evaluation Using ECG, Holter Monitoring, and Implantable Loop Recorders to Monitor Absolute and Clinical Effectiveness

2018 ◽  
Vol 2018 ◽  
pp. 1-7 ◽  
Author(s):  
Karapet Davtyan ◽  
Victoria Shatakhtsyan ◽  
Hermine Poghosyan ◽  
Alexandr Deev ◽  
Alexey Tarasov ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Clinical Effectiveness ◽  
Holter Monitoring ◽  
Patient Characteristics ◽  
Cryoballoon Ablation ◽  
End Point ◽  
Radiofrequency Current ◽  
Implantable Loop Recorders

Introduction. While several studies have compared the radiofrequency current (RFC) and cryoablation for the treatment of patients with atrial fibrillation (AF), no study has monitored the long-term outcomes with the usage of implantable loop recorders (ILRs). Methods. We enrolled 89 consecutive patients with nonvalvular paroxysmal AF (N=44 for RFC and N=45 for cryoballoon). The primary efficacy end point was the assessment of effectiveness for each group (RFC versus cryoballoon) when examining freedom from arrhythmia by monitoring with ECG, Holter, and implantable loop recoder (ILR). The primary safety end point compared rates of adverse events between both groups. The secondary efficacy end point examined the duration of the postablation blanking period from ILR retrieved data. Results. The mean age of the study population was 56.6±10.2 years, and the follow-up duration was 12 months. There were no differences in baseline patient characteristics between groups. At 12 months, the absolute effectiveness (measured by ILR) was 65.9% in the RFC group and 51.1% in the cryoballoon group (OR = 1.85; 95% CI: 0.79–4.35; p=0.157), and the clinical effectiveness (measured by ECG and Holter) was 81.8% in the RFC group and 55.6% in the cryoballoon group (OR = 3.6; 95% CI: 1.37–9.46; p=0.008). There was no difference in safety between both groups. Asymptomatic episodes were significantly more present in the RFC group as measured by ILRs (p<0.010). In cryoballoon group, arrhythmia episodes were recorded equally irrespective of the follow-up method (i.e., ECG and Holter versus ILR (p>0.010)). The blanking period does not seem to be as important in cryoballoon as compared to RFC. Conclusion. RFC and cryoballoon ablation had similar absolute effectiveness at 12 months. ECG and Holter were effective when assessing the efficacy of the cryoballoon ablation; however, in the RFC group, ILR was necessary to accurately assess long-term efficacy.

Detection of atrial fibrillation in patients with embolic stroke of undetermined source by prolonged monitoring with implantable loop recorders

2017 ◽  
Vol 117 (10) ◽  
pp. 1962-1969 ◽  
Author(s):  
Carsten Israel ◽  
Alkisti Kitsiou ◽  
Malik Kalyani ◽  
Sameera Deelawar ◽  
Lucy Ekosso Ejangue ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Magnetic Resonance Tomography ◽  
Embolic Stroke ◽  
Secondary Stroke Prevention ◽  
Detection Algorithms ◽  
Therapeutic Consequences ◽  
Cerebral Microangiopathy ◽  
Implantable Loop Recorders ◽  
Work Up

SummaryRecently, the clinical entity embolic stroke of undetermined source (ESUS) has been defined for patients with ischemic strokes, where neither a cardioembolic nor a non-cardiac source can be detected. These patients may suffer from asymptomatic atrial fibrillation (AF), terminating spontaneously and thus eluding detection. Implantable loop recorders (ILR) with automatic AF detection algorithms can detect short-lasting, subclinical AF. The aim of this study was to prospectively assess and predict AF detection in patients with ESUS using ILR with daily remote interrogation. Patients with acute ESUS received an ILR, were seen every 6 months and additionally interrogated their ILR daily using remote monitoring. The incidence of AF detection was assessed and parameters which might predict AF detection (clinical and from magnetic resonance tomography) were analysed. ILR implantation was performed in 123 patients on average 20 days after stroke. During a mean follow-up of 12.7±5.5 months, AF was documented and manually confirmed in 29 of 123 patients (23.6%). First AF detection occurred on average after 3.6±3.4 months of monitoring. Patients with AF were on average older, had a higher CHA2DS2-VASc score and more often cerebral microangiopathy. In conclusion, AF can be documented in approximately 25% of patients with the diagnosis of ESUS after careful work-up within a year of monitoring by an ILR and daily remote interrogation. This had important therapeutic consequences (initiation of anticoagulation for secondary stroke prevention) in these patients.

Myeloablative Allogeneic Hematopoietic Cell Transplantation Performed without Routine Inpatient Admission: A Single Center Experience of 462 Consecutive Patients

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 661-661 ◽  
Author(s):  
Asad Bashey ◽  
Xu Zhang ◽  
Stacey Brown ◽  
Katelin Jackson ◽  
Melhem Solh ◽  
...  
Keyword(s):  
Stem Cell ◽  
Outpatient Clinic ◽  
Conditioning Regimen ◽  
Patient Characteristics ◽  
Hematopoietic Cell ◽  
Inpatient Admission ◽  
Inpatient Stay ◽  
Outpatient Management ◽  
To Receive

Abstract Patients undergoing allogeneic hematopoietic cell transplants (Allo-HCT) using myeloablative preparative regimens are usually admitted to an inpatient transplant unit from the start of the conditioning regimen until hematopoietic recovery (on average 25-35 days). Historically, the rationale for routine inpatient care during this period has been the facilitation of administration of parenteral medications, prevention of mold infections and the monitoring and management of acute toxicities. However, advances in supportive care and other technologies may allow outpatient management during this period. We analyzed outcomes of all consecutive patients who underwent myeloablative allo-HCT as defined by the CIBMTR (Giralt 2009, BBMT) with planned total outpatient management at our center. Patient characteristics and outcome data were prospectively entered into our institutional database from which they were extracted for this analysis. Patients were scheduled to receive their conditioning regimen and post-transplant care in our purpose-built outpatient clinic. Patients received their stem cell infusion on the inpatient unit and were planned to be discharged home the same day except patients receiving haploidentical transplants who were planned to be discharged on day +5 to accommodate the early cytokine release syndrome commonly seen in such patients (Solomon BBMT 2012). Subsequent admissions were for significant complications necessitating inpatient management only. Our technical approach to total outpatient management of myeloablative allo-HCT was as previously described (Solomon BMT 2010, 45: 468-475). Patients (n=462) were transplanted consecutively between 4/08 and 12/15. Patient characteristics were: median age 46; male (53%); race - white 79%, black 18%, Asian 2%; diagnosis- AML 42%, ALL 21%, MDS/MPS 21%, NHL/HL/CLL 13%, other 3%; donor type - MRD 48%, MUD 35%, Haplo 17%, CBT <1%; graft source- PBSC 87%, BM 12%, BM+PBSC 1%; regimen-busulfan based 60%, TBI based 39%, other 1%; DRI -low 16%, intermediate 48%, high 26%, v. high 10%; HCT-CI- 0-2 (64%), ≥3(36%). The conditioning regimen was entirely delivered in the outpatient clinic as planned in 377 patients (82%). Of 85 (18%) patients who received some of their conditioning regimen in the inpatient setting, in 42(49%) this was to receive drugs not administrable or reimbursed in the outpatient setting, and in 43(51%) it was for management of toxicity. The majority of patients were discharged within 24 hours of stem cell infusion (311 -67%) with the median day of discharge for the remaining patients being d+13 (range d+2 to d+75). Following discharge after stem cell infusion, 82 patients (18%) were never readmitted, days to readmission for the remainder were 0-5 (40%), 6-9 (24%), > 10 (18%). For readmitted patients, most frequent reasons were - febrile neutropenia 33%, mucositis 29%, and lower GI toxicity 4.5%. Median total length of inpatient stay through d+100 was 16 d (range 1-98). Fungal infections were documented in only 3 patients (1%) through d +100. With a median follow-up for surviving patients of 52 months (6-218 months), K-M estimates of survival and DFS at 1 yr are 70% and 61% and at 4 years are 52% and 47% respectively. Cumulative incidences (CI) of non-relapse mortality (NRM) and relapse at 1 yr are 17% and 21% and at 4 yrs are 24% and 29% (Fig.1). CI of acute GVHD grade 2-4 and 3-4 at 6 months were 28% and 10%. CI of moderate to severe, and severe chronic GVHD at 4 years were 30% and 12%. On multivariate analysis, receipt of any part of the conditioning regimen as inpatient was a significant negative factor for survival (HR 1.99, p<0.001), DFS (HR 1.74, p =0.001) and NRM (HR 2.06, p=0.004). These data show that myeloablative allo-HCT performed without routine inpatient admission from conditioning through neutrophil recovery is feasible with low rates of NRM and fungal infection. Median total inpatient stay through d +100 can be reduced to 16 days and nearly 20% of patients can avoid any inpatient stay through d +100. With mature follow-up outcomes appear similar or superior to those commonly reported using a traditional inpatient approach. Figure 1. Figure 1. Disclosures No relevant conflicts of interest to declare.

P4139Prediction of atrial fibrillation in embolic stroke of unknown source

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
F T Range ◽  
D P Peters ◽  
T Zeus ◽  
S Jander ◽  
P Mueller ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Real Life ◽  
Patient Characteristics ◽  
Embolic Stroke ◽  
Baseline Heart Rate ◽  
Loop Recorder ◽  
Chads2 Score ◽  
Unknown Source ◽  
Significant Difference

Abstract Background Atrial fibrillation (AF) is one of the leading cardiogenic causes for embolic stroke of unknown source (ESUS). Its incidence is growing with patients' age. Detection and rule out of AF is complex and cumbersome. The best method is an implantable loop recorder (ILR). In patients elder than 60 years, incidence of AF is reported incongruently and reliable patient characteristics that can predict a low or high risk for AF are scarce. Purpose This study reports real life incidences of AF in a group of patients undergoing ILR after ESUS. It aims to depict age dependency of AF and to identify potential confounding factors. Methods In a single center study, we analysed 111 patients (age=62±13 years, nmale=65) who received an ILR in our centre following ESUS. Patient characteristics, brain imaging, hemodynamic monitoring, blood pressure, electrocardiography, holter ecg and echocardiography data from the initial hospital stay and ILR follow-up over a mean of 460 days were analysed. Primary endpoint was the recording of AF during follow-up. Results AF was detected in 23% of all patients. Patients with AF were significantly elder than those without AF (p=0.01). Incidence of AF was in Patients <60y: 14%, 60–69y: 13%, 70–79y: 45%, >80y: 67%. We observed a significant difference in AF incidence comparing patients younger and elder than 70 years (p=0.034). Both, CHADS-Vasc (p=0.036) and HATCH-scores (p=0.018) were higher in the AF group while the simple CHADS2 Score missed significance (p=0.068). PQ duration was longer in AF patients (p=0.022) and baseline heart rate at admission was lower (p=0.027). NIHSS scores were lower in the AF group at admission (2.97 vs. 4.10; p=0.049) but due to less neurological improvement in the AF group, this difference faded until dismission (1.09 vs 1.79 p=ns). Conclusions In our real life ILR group following ESUS, strongest predictor of AF was age. Pivot point rather was at 70 than at 60 years of age.

Abstract TP399: Incremental Healthcare Burden Associated with Dyspepsia Among Nonvalvular Atrial Fibrillation Patients: Implications for Anticoagulation Therapy

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Michael H Kim ◽  
Kelly F Bell ◽  
Dinara Makenbaeva ◽  
Daniel Daniel Wiederkehr ◽  
Jay Lin ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Insurance Coverage ◽  
Anticoagulation Therapy ◽  
Patient Characteristics ◽  
Nonvalvular Atrial Fibrillation ◽  
Chads2 Score ◽  
Entire Study ◽  
Healthcare Burden ◽  
Gi Bleed

Background: Dyspepsia is common among nonvalvular atrial fibrillation (NVAF) patients and may influence stroke preventative medication choice, such as warfarin and dabigatran, especially when bleeding is a concern. This study evaluated the incremental healthcare burden associated with dyspepsia among NVAF patients. Methods: NVAF patients ≥18 years of age with continuous insurance coverage were identified (1/1/2007-12/31/2009) from the MarketScan® Commercial and Medicare Research Databases. Patients with at least 1 inpatient or 2 outpatient dyspepsia diagnoses within 12 months following any NVAF diagnosis were categorized as dyspepsia cohort, with patients without any dyspepsia diagnosis during the entire study period categorized as non-dyspepsia cohort. Of the overall dyspepsia/non-dyspepsia cohorts, patients were matched by key patient characteristics. Healthcare usage and costs were measured in a 12-month follow-up period. Results: Among NVAF patients, 10.2% had dyspepsia. For the dyspepsia cohort (n=14,556) vs. unmatched non-dyspepsia cohort (n= 127,766), mean CCI (2.4 vs. 1.6, p<0.0001), CHADS2 score (1.8 vs. 1.6, p<0.0001), hospitalizations (dyspepsia-related, GI-related, GI-bleed related, any cause), associated inpatient costs, outpatient usage and costs, as well as pharmacy usage and costs were greater. After matching, a lesser proportion of patients in the dyspepsia cohort used warfarin (49% vs. 57%, p<0.0001) and had significantly higher healthcare resource usage and costs vs. the non-dyspepsia cohort during the follow-up period (Table). Conclusions: The incremental healthcare burden associated with dyspepsia among NVAF patients is significant and appears associated with less warfarin usage. Further data on dyspepsia as a barrier to anticoagulation in NVAF are needed.

scholarly journals LO004: Short-term risk of arrhythmias among syncope patients presenting with atrial fibrillation/flutter to Canadian emergency departments

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S31-S31
Author(s):  
C. Toarta ◽  
K. Kwong ◽  
I.G. Stiell ◽  
M.A. Mukarram ◽  
M. Taljaard ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Odds Ratio ◽  
Multivariable Analysis ◽  
Patient Characteristics ◽  
Baseline Risk ◽  
Future Research ◽  
Short Term ◽  
Secondary Outcomes ◽  
A Prospective Study

Introduction: Short-term risk of arrhythmia or death among emergency department (ED) syncope patients with atrial fibrillation/flutter (AFF) has not been reported in the literature. Our objectives were to assess the incidence and the independent risk of 30-day arrhythmia or death for syncope patients with AFF after ED disposition. Methods: We conducted a prospective study at 6 Canadian academic EDs to include adults with syncope. We collected demographic, clinical and ECG characteristics while our outcome assessments were completed by medical records review and by telephone follow-up of patients after 30 days. Primary outcome was arrhythmia or death within 30-days after ED disposition and secondary outcomes included non-arrhythmic cardiac and non-cardiac outcomes. We performed descriptive and logistic regression analyses. Results: We enrolled 4,266 patients: mean age 53.4 years, 55.4% females, and 8.5% with AFF. After excluding those with outcomes in the ED, lost to follow-up and those with other non-sinus rhythms, 3,417 patients in the sinus and 280 patients in the AFF groups were analyzed. The incidence of arrhythmia or death was significantly higher in the AFF group (Relative Risk 5.1; 95% CI 3.1-8.4; p<0.0001) but there were no significant differences in secondary outcomes between the groups. The unadjusted odds ratio for 30-days arrhythmia or deaths among ED syncope patients with AFF was 5.4 (95% CI 3.2- 9.2). After adjusting for important baseline risk factors by multivariable analysis, the odds ratio for arrhythmia or death in patients with AFF was 1.5 (95% CI 0.8-2.7). Conclusion: The risk of AFF for 30-day arrhythmia or death among syncope patients after ED disposition is higher but is attenuated when adjusted for important patient characteristics. Future research should assess long-term outcomes among syncope patients with AFF to guide follow-up after ED discharge.

Significance of Flow Cytometric and Mutational Findings in Patients with Cytopenias and Limited or No Signs of Myelodysplasia By Cytomorphology

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 1671-1671
Author(s):  
Wolfgang Kern ◽  
Manja Meggendorfer ◽  
Claudia Haferlach ◽  
Susanne Schnittger ◽  
Torsten Haferlach
Keyword(s):  
Flow Cytometry ◽  
Normal Karyotype ◽  
Initial Assessment ◽  
Employment Equity ◽  
Initial Flow ◽  
Flow Cytometric ◽  
Equity Ownership ◽  
Diagnostic Work ◽  
Work Up

Abstract Introduction: The diagnosis of myelodysplastic syndromes (MDS) has been clearly defined by the WHO classification but remains a challenge in a significant number of cases with cytomorphologically borderline findings and normal karyotype. Furthermore, flow cytometry is capable of identifying MDS-specific aberrant antigen expression yet its value in these borderline cases as well as in those even without cytomorphologic findings of myelodysplasia remains to be clarified. Follow-up analyses as well as extension of diagnostic work-up to screening for molecular mutations may give further insight. Aims: Assess the significance of cytomorphologically borderline dysplastic changes and of flow cytometric MDS-related findings in the absence of a clear-cut diagnosis of MDS by screening for molecular mutations and by diagnostic reassessment during follow-up. Patients and methods: Bone marrow samples of 322 patients were assessed for suspected MDS by cytomorphology, flow cytometry and cytogenetics in parallel from 08/2005 to 11/2014 which 1) did not reveal a definite diagnosis of MDS by cytomorphology, 2) had a normal karyotype and 3) had at least one follow-up bone marrow assessment. By cytomorphology, 159 (49%) cases had borderline dysplastic findings while 163 (51%) had no sign of MDS. By flow cytometry, 138 (43%) cases had findings in agreement with MDS according to ELN criteria (Westers et al., Leukemia 2012; at least three aberrantly expressed antigens), 141 (44%) had borderline findings (one or two aberrantly expressed antigens) and 43 (13%) had no signs of MDS. A total of 699 follow-up samples were analyzed (median 2/patient). The median follow-up amounted to 3.0 years. In 147/322 patients (46%) screening for molecular mutations was performed on the initial samples, respectively, targeting a total of 20 genes (median 4 genes/patient, range 1-20). Analyzed genes were ASXL1, TET2, RUNX1, SRSF2, BCOR, DNMT3A, IDH2, NPM1, SF3B1, TP53, ZRSR2, CBL, CSF3R, ETV6, KDM6A, KRAS, MLL, SETBP1, SMC3 and U2AF1. Results: A total of 145 patients (45%) were diagnosed with MDS by cytomorphology during follow-up. The median duration until diagnosis amounted to 3.4 years. Regarding initial cytomorphology, more cases with borderline dysplastic findings were diagnosed MDS at follow-up than those without any dysplastic findings (82/159 (52%) vs 63/163 (39%), p=0.025). However, the duration until diagnosis of MDS did not differ significantly between the two groups (median 2.6 vs 3.4 years). Regarding initial flow cytometry, more cases with findings in agreement with MDS were diagnosed MDS by cytomorphology at follow-up than those without (80/138 (58%) vs 65/184 (35%), p<0.001) while there was no difference between cases with one or two aberrantly expressed antigens at initial assessment vs those with none (51/141 (36%) vs 14/43 (33%), n.s.). The duration until diagnosis of MDS significantly differed between the groups as defined by flow cytometry and was shortest in cases in agreement with MDS at initial assessment and longest in those without any aberrantly expressed antigen (median 1.9 vs 4.1 vs 5.6 years, p<0.001). Overall survival (OS) for all cases was 80% at 5 years. While initial cytomorphologic results revealed no impact on OS, patients with an initial flow cytometric result in agreement with MDS tended to have a shorter OS (5 year OS 70% vs 88%, p=0.12). Molecular screening revealed mutations in 21/147 patients (14%) at initial assessment. Mutated genes included ASXL1 (mutated in 6 patients), TET2 (6), RUNX1 (3), SRSF2 (3), as well as 2 cases each for BCOR, DNMT3A, IDH2, NPM1, SF3B1, TP53 and ZRSR2 and 1 case each for CBL, CSF3R, ETV6, KDM6A, KRAS, MLL, SETBP1, SMC3 and U2AF1. The percentage of patients with at least one mutation did not differ between cases with borderline dysplastic findings by cytomorphology as compared to those without any dysplastic findings. In contrast, significantly more cases with findings in agreement with MDS by flow cytometry had at least one mutation as compared to those with one or two aberrantly expressed antigens as well as to those with none (15/71 (21%) vs 6/58 (10%) vs 0/18, p=0.012). Conclusions: This data strongly supports the need to define the role of flow cytometry in the diagnostic work-up in suspected MDS and argues for an integrated approach with cytomorphology and cytogenetics. Implementation also of molecular data on mutations may further improve the validity of MDS diagnostics. Disclosures Kern: MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Meggendorfer:MLL Munich Leukemia Laboratory: Employment. Haferlach:MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Schnittger:MLL Munich Leukemia Laboratory: Employment, Equity Ownership. Haferlach:MLL Munich Leukemia Laboratory: Employment, Equity Ownership.

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