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What about an echocardiogram looking for valve abnormality left atrial clot l atrium dilation foramen ovale and ejection fraction - heart failure is one point on the risk scores ?
Great questions. If you can get a transesophageal echo in your ED before you cardiovert, yes, this is an option for patients whom you want to cardiovert but haven't been on at least 3 weeks of therapeutic anticoagulation, and who don't meet the 48 hour cut-off (which is now 12-24 hours, if your stroke risk score is higher, according to several guidelines groups). This is to directly rule out an atrial clot, as you say. If you go this route the patient must be anticoagulated afterward for 4 weeks minimum (and after that according to their stroke risk score), even if no clot is seen.
That said, it does not look like a fun procedure to me. Personally, if I were the patient I'd take my 3 weeks of rate-control pill and OAC any day over a TOE in the ED - it looks awful! I realize the midaz may wipe out that gawd-awful memory, but what if it doesn't? How badly do you have to want to be back in sinus rhythm immediately (vs in 3 weeks) to put up with that? There is also a study (Balllard DW et al, Ann Emerg Med 2015) that shows that ED AF patients who get rate-controlled and OAC for a month vs cardioverted in the ED report the no difference in quality of life scores 30 days later (the validated AF QOL tool measured symptoms, activity limitations, etc). So what's the rush? But that's just my personal opinion...
An echo isn't necessary if the patient has no history of valve abnormality and is within the recommended time window for cardioversion. Specifically, the only valve abnormalities that would preclude cardioversion on their own (because they render the patient very high risk of stroke) in the ED are (1) a mechanical valve, (2) rheumatic MS, or (3) moderate to severe non-rheumatic MS.
Many patients with AF will have dilation of their L atrium, as that may be one of the mechanisms by which hypertension leads to the development of AF. At some point their LA size should be assessed via (transthoracic) echo, but not urgently before cardioversion.
I have never seen foramen ovale addressed in any guidelines: AHA, CCS, ESC, NICE, etc. Not enough data to say, is my guess, but probably many patients have it and we don't know they do, and we proceed with cardioversion. The rates of subsequent stroke are extremely low, and if you put everyone on OAC following cardioversion according to their stroke risk score (i.e. CHADS-VASc 2+ if male, 3+ if female, if you are using AHA risk score), then even that risk is effectively gone.
Yup, heart failure is one point on all risk scores. So is hypertension, which technically has a slightly lower 1 year risk of stroke associated with it compared to a history of heart failure, but for clinical use we just give them both the same 1 point.
Thanks for your reply .But do you really need a TOE to exclude atrial clotlarge left atriumejection fractionand cardiovascular abnormalities .Can bedside echo in a skilled team detect these abnormalities ?
If the patient is very low risk for stroke and within the 48 hour window of AF onset (or 12-24 hours, if they have a higher stroke risk score, and depending on which set of guidelines you choose to follow), you do NOT need a TOE to proceed with cardioversion. For ANY purpose (atrial clot, atrial size, etc). [Sorry about the BOLD typeface, which reads like shouting - I can't seem to get italics to work.] It is only if the AF onset is NOT within the last 48 hours (or 12-24 hours if they have a higher CHADS2/CHADS-65/potentially CHADS-VASc score) that you need a TOE in order to rule out atrial clot (if the patient has not been on consistent OAC x 3 weeks) before you proceed to cardioversion.
The other findings on TOE (left atrial diameter, EF, etc) are for chronic care only. They are not relevant to the ED cardioversion.
In Canada, where ED cardioversions have been very common since the early 2000s, few of us can get a TEE before ED cardioversion - if that was a requirement, our number of ED cardioversions would drop by about 95%!
Point-of-care echocardiography (used by emergency physicians) differs from comprehensive echocardiography in that it is focused and goal-oriented, so it is used to answer whether a specific pathology is present or absent. Measurements are qualitative: in general no specific measurements are made. The list of issues evaluated by POC echocardiography is very specific, and includes presence of pericardial effusion and EF (visual estimation of fractional shortening, E-point septal separation, and end-diastolic chamber diameter). At this time it does not include assessment for atrial clot. I know a few emergency physicians who have the skills to perform a transesophageal echo (most commonly during cardiac arrest or in the setting of undifferentiated shock), but having the skills to do (a) a transesophageal echo (as opposed to transthoracic) AND (b) have the requisite number of scans to confidently detect atrial clot, is not within the skill set of any emergency physicians that I know.
Hope that helps!
I wish the EM RAP hosts (as great as they are) would stop saying to "call the primary care physician" to discuss medical care of patients. Maybe I am on a different planet, or Canada is vastly inferior to the US in terms of medical care. But in 20 years of EM residency and independent practise, I have never been able to reach or spoken to a primary care doctor of a patient in the ED and coordinated their care. Most of the day is not 0900-1700, it is 1700-0900. Let's please stop saying this on these segments as it just is not a reality for most average emergency physicians.
I think that the reality is that we just don't have time to be making phone calls from the ED during a busy shift (and aren't the shifts always busy?). Even if we got the clerical staff to call the family physician's office, and then for them to wait on the line for the family physician to be finished with his or her patient while we went off to see another patient, that would introduce multiple interruptions in our care of ED patients, particularly if we did that several times a day - and we know from the literature that interruptions are a high-risk time for errors. Not to mention, as you say, the greatest volume of ED patients are seen during hours when the primary care offices are shut, and if you call, as I have, you typically get an answering machine that (a) doesn't take messages, and (b) directs you to go to the ED if you need care (Argh!! I AM the ED...!)
So I think we need a truly systemic solution to ensuring followup care for these patients. I reached that conclusion some years ago when I was doing my AF research, and as such I am now working on a CIHR-funded study looking at an online scheduling system of primary care appointments (with your own family physician's office) for EDs.
Integrated healthcare systems can likely do this already, such as Kaiser-Permanente, VA, etc. The difference is that they have an integrated IT system with safeguards for PHI (personal health information). Outside of these groups, family physicians are a very disparate group (particularly in Canada, but I think in much of the U.S. too), both overall and in terms of EHR integration. For example, while I can get most ED chiefs in my province on the phone within a day or 2 (through one channel), who can in turn speak to their ED practice group members, I can't make contact with the many family physicians in the province anywhere near as easily. That is the first issue, because I can't easily ask family physicians to offer a couple of open appointments per week (on my online platform) for their patients who are being discharged from an ED. The second is doing that securely and the issues with privacy law. I can only tell you that I'm working on it (and have been since 2014)...!
(I don't think it is that different for the U.S. and Canada, with the exception of the integrated systems like KP and VA. U.S. challenges may be even greater because of health insurance [or lack of it] and not having a family physician, although the latter is a problem in many Canadian provinces too. The Commonwealth studies have repeatedly suggested that it takes even longer for Canadians to get an appointment with their family physician that it does Americans. I did a scoping review of post ED followup care in AEM in Feb 2017, if you are interested in the topic: https://onlinelibrary.wiley.com/doi/epdf/10.1111/acem.13125 [Please excuse the shameless self-reference!])
This statement (was the same on the audio) makes no sense: They found that when comparing two patients who had atrial fibrillation of less than 12 hours duration, the risk of stroke was highest in the 12-24 hours group. I assume it was suppose to say when comparing patients with less than 48 hours duration?
I think I found the statement on the audio (around 1:10): "comparing to patients who had AF of < 12 hours duration, the risk of stroke was highest in the 12-24 hour group..." It is not comparing TWO patients who had AF < 12h (I'm not sure if that is the issue though). That Finnish study that we were discussing (Nuotio et al, JAMA, 2014. 312(6);647-8) divided duration of AF into three time periods: (1) < 12 h, (2) 12-24 h, and (3) 24-48 h. Those authors put an "AF duration" variable into their regression model using those three levels, and they used the < 12 h group of patients as the reference or comparator group. The dependent variable of the model (the outcome they wanted to predict, after adjusting for the variables entered into the model) was clinical stroke or systemic embolism within 30 days. The model found an OR of 4.0 for the 12-24 hour duration group (again, that is compared to the < 12h AF duration patients in the cohort), and an OR 3.3 for 24-48 hours (again, vs < 12h patients).
I agree, it doesn't make sense in terms of underlying pathophysiology and Bradford hill criteria (dose-response relathionship): if the issue is that longer duration in AF leads to more likelihood of a stroke/thromboembolism, then the odds of that should be highest in the 24-48 hour group (OR 3.3), not the 12-24 hr group (OR 4.0). But the # of outcomes in the study as very small (40 outcomes), so the model couldn't adjust for many potential confounders (or it would be overfit). Unfortunately a large enough study would require thousands upon thousands of patients, so this is the best we have, for now.
Let me know if that doesn't answer your question.
Do you know why we can't we convert all patients in ed after a negative d dimer alone regardless of duration of symptoms and without TEE or initiating anticoagulation? We essentially already use it to rule out a clot in pulmonary arteries and RA/RV, it's hard to imagine a clot in LA/LV with positive d dimer. Has this question just not been studied and validated yet?
What you do matters.