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Active management of atrial fibrillation or flutter in emergency department patients with renal impairment is associated with a higher risk of adverse events and treatment failure

  • Frank X. Scheuermeyer (a1), Hubert Wong (a2), Tyler W. Barrett (a3), Jim Christenson (a1), Eric Grafstein (a1), Brian Grunau (a1) (a2), Matt Wiens (a1) and Grant Innes (a4)...

Abstract

Objective

Atrial fibrillation or flutter (AFF) patients with renal impairment have poor long-term prognosis, but their emergency department (ED) management has not been described. We investigated the association of renal impairment upon outcomes after rate or rhythm control (RRC) including ED-based adverse events (AE) and treatment failure.

Methods

This cohort study used an electrocardiogram database from two urban centres to identify consecutive AFF patients and reviewed charts to obtain comorbidities, ED management, including RRC, prespecified AE, and treatment failure. Patients were dichotomized into a normal estimated glomerular filtration rate (eGFR) > 60 mL/min/1.73 m2) or impaired renal function (“low eGFR”). Primary and secondary outcomes were prespecified AEs and treatment failure, respectively. We calculated 1) adjusted excess AE risk for patients with decreased renal function receiving RRC; and 2) adjusted odds ratio of RRC treatment failure.

Results

Of 1,112 consecutive ED AFF patients, 412 (37.0%) had a low eGFR. Crude AE rates for RRC were 27/238 (11.3%) for patients with normal renal function and 26/103 (25.2%) for patients with low eGFR. For patients with low eGFR receiving RRC, adjusted excess AE risk was 13.7%. (95% CI 1.7 to 25.1%). For patients with low eGFR, adjusted odds ratio for RRC failure was 3.07. (95% CI 1.74 to 5.43)

Conclusions

In this cohort of ED AFF patients receiving RRC, those with low eGFR had significantly increased adjusted excess risk of AE compared with patients with normal renal function. Odds of treatment failure were also significantly increased.

Contexte

La fibrillation auriculaire et le flutter auriculaire (FFA) chez les patients atteints d'un dysfonctionnement rénal comportent un pronostic sombre à long terme, mais la documentation reste silencieuse sur leur prise en charge au service des urgences (SU). L’étude avait donc pour objet l'incidence du dysfonctionnement rénal sur les résultats cliniques après une réduction de la fréquence (RF) cardiaque ou une régularisation du rythme (RR) cardiaque, dont la survenue d’événements indésirables (EI) au SU ou l’échec du traitement.

Méthode

Il s'agit d'une étude de cohorte qui visait à repérer des patients consécutifs atteints de FFA, à l'aide de données sur les ECG recueillies dans deux grands centres urbains, et à examiner les dossiers médicaux à la recherche de renseignements sur les affections concomitantes; la prise en charge au SU, dont les traitements par RF/RR; les EI prédéterminés et l’échec du traitement. Les patients ont été divisés en deux groupes : fonctionnement rénal normal (débit de filtration glomérulaire estimé [DFGe] ≥ 60 ml/min/1,73 m2) et fonctionnement rénal anormal (DFGe faible). Les critères principal et secondaire d’évaluation comprenaient des EI prédéterminés et l’échec du traitement, respectivement. Ont été calculés 1) le risque excédentaire rajusté d'EI chez les patients atteints d'un dysfonctionnement rénal qui ont été soumis à une RF/RR; et 2) le risque relatif approché [RRA] rajusté d’échec du traitement par RF/RR.

Résultats

Sur 1112 patients consécutifs examinés pour FFA au SU, 412 (37,0%) avaient un faible DFGe. Le taux brut d'EI après une RF/RR était de 27/238 (11,3%) chez les patients ayant un fonctionnement rénal normal et de 26/103 (25,2%) chez les patients ayant un faible DFGe. Parmi ceux qui ont été soumis à une RF/RR dans ce dernier groupe, le risque excédentaire rajusté d'EI s'est établi à 13,7% (IC à 95% : 1,7-25,1%) et le RRA rajusté d'ET par RF/RR, à 3,07 (IC à 95% : 1,74-5,43).

Conclusion

Dans cette cohorte composée de patients atteints de FFA et traités par RF/RR au SU, ceux qui avaient un faible DFGe ont connu une augmentation importante du risque excédentaire rajusté d'EI comparativement aux patients qui avaient un fonctionnement rénal normal. Il en allait de même pour le RRA d’échec du traitement.

Copyright

Corresponding author

Correspondence to: Frank X. Scheuermeyer, Department of Emergency Medicine, St Paul's Hospital and the University of British Columbia, 1081 Burrard St, Vancouver, BC, Canada V6Z 1Y6; Email: frank.scheuermeyer@gmail.com

References

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