Aim: Medication for the pharmacological cardioversion of atrial fibrillation (AF) and atrial flutter (AFL) is applied either in a fixed dose or adapted to body weight. Individual body weight might be ...a relevant confounder for anti-arrhythmic treatment success. Therefore, the aim of this study was to elucidate the impact of body weight on pharmacological cardioversion success, comparing weight adapted (Vernakalant) and fixed dose (Ibutilide) pharmacotherapeutic cardioversion regimes. Methods: Within this prospective observational trial, a total of 316 episodes of AF and AFL were enrolled. Patients were stratified in either a Vernakalant (n = 181) or Ibutilide (n = 135) treatment arm, based on the chosen regime, for direct comparison of treatment efficacy. Results: Conversion to sinus rhythm was achieved in 76.3% of all cases. Of note, there was no difference comparing the Vernakalant and Ibutilide treatment arms (Vernakalant 76.2% vs. Ibutilide 76.3%; p = 0.991). Within the whole study population, decreasing conversion rates with increasing body weight (adjusted odds ratio (OR) = 0.69 (0.51–0.94); p = 0.018) were observed. An independent effect of body weight within the Ibutilide treatment arm was noted, which remained stable after adjustment for potential confounders (adjusted OR = 0.55 (0.38–0.92), p = 0.022. Conclusion: Both, the Vernakalant and Ibutilide treatment arms showed comparable rates of treatment success in pharmacotherapeutic cardioversion of AF and AFL. Of utmost importance, we observed that the fixed dose of Ibutilide—as compared to the weight-adapted dose of Vernakalant—showed a reduced treatment success with increasing body weight.
Computed tomography (CT) could be a suitable method for acute exclusion of left atrial appendage thrombus (LAAT) prior to cardioversion of atrial fibrillation (AF) and atrial flutter (AFL) at the ...emergency department. Our aim was to present our experiences with this modality in recent years.
This registry-based observational study was performed at the Department of Emergency Medicine at the Medical University of Vienna, Austria. We studied all consecutive patients with AF and AFL who underwent CT between January 2012 and January 2023 to rule out LAAT before cardioversion to sinus rhythm was attempted. Follow-ups were conducted by telephone and electronic medical records. The main variables of interest were the rate of LAAT and ischemic stroke at follow-up.
A total of 234 patients (143 61% men; median age 68 years IQR 57-76, median CHA
DS
-VASc 2 IQR 1-4) were analyzed. Follow-up was completed in 216 (92%) patients after a median of 506 (IQR 159-1391) days. LAAT was detected in eight patients (3%). A total of 163 patients (72%) in whom LAAT was excluded by CT were eventually successfully cardioverted to sinus rhythm. No adverse events occurred during their ED stay. All patients received anticoagulation according to the CHA
DS
-VASc risk stratification, and no patient had suffered an ischemic stroke at follow-up, resulting in an incidence risk of ischemic strokes of 0% (95% CI 0.0-1.2%).
LAAT was rare in patients admitted to the ED with AF and AFL who underwent cardiac CT prior to attempted cardioversion. At follow-up, no patient had suffered an ischemic stroke. Prospective studies need to show whether this strategy is suitable for the acute treatment of symptomatic AF in the emergency setting.
We report a case of hemodynamic instability due to bradycardia on the basis of severe hyperkalemia. Diabetic ketoacidosis and acute kidney injury together with polypharmacy triggered the acute onset. ...Potentially life‐threatening hyperkalemia is often induced by drug interactions. ECG features may be crucial for diagnosis, and treatment depends on setting and resources.
We report a case of hemodynamic instability due to bradycardia on the basis of severe hyperkalemia. Diabetic ketoacidosis and acute kidney injury together with polypharmacy triggered the acute onset. Potentially life‐threatening hyperkalemia is often induced by drug interactions. ECG features may be crucial for diagnosis, and treatment depends on setting and resources.
National authorities have introduced measures as lockdowns against spreading of COVID-19 and documented incidences of multiple non-COVID-19 diseases have dropped. Yet, data on workload dynamics ...concerning atrial fibrillation and electrical cardioversion whilst a national lockdown are scarce and may assist in future planning.
Documented cases of atrial fibrillation and respective electrical cardioversion episodes at the Emergency Department of the Medical University of Vienna, Austria, from 01/01/2020 to 31/05/2020 were assessed. As reference groups, those incidences were calculated for the years 2017, 2018, and 2019. Inter- and intra-year analyses were conducted through Chi-square test and Poisson regression.
A total of 2,310 atrial fibrillation-, and 511 electrical cardioversion episodes were included. We found no significant incidence differences in inter-year analyses of the time periods from January to May, or of the weeks pre- and post the national lockdown due to the COVID-19 pandemic. However, the intra-year analysis of the year 2020 showed a trend toward decreased atrial fibrillation incidences (rate-ratio 0.982, CI 0.964-1.001,
= 0.060), and significantly increased electrical cardioversion incidences in the post-lockdown period (rate ratio 1.051, CI 1.008-10.96,
= 0.020).
The decreased atrial fibrillation incidences are in line with international data. However, an increased demand of electrical cardioversions during the lockdown period was observed. A higher threshold to seek medical attention may produce a selected group with potentially more severe clinical courses. In addition, lifestyle modifications during isolation and a higher stress level may promote atrial fibrillation episodes to be refractory to other therapeutic approaches than electrical cardioversion.
Rapid restoration of sinus rhythm is an integral part of the management of recent-onset atrial fibrillation. We aimed to assess safety and efficacy of vernakalant, a multi-channel blocking agent, in ...combination with external electrical cardioversion.
This prospective cohort study comprised 230 patients (female 35%; median age 50 IQR 42–55) with recent-onset AF presenting to a university tertiary care center during a 6-year period. Management included intravenous vernakalant followed by electrical cardioversion in case of pharmacological failure.
Within 11 min (IQR 8–29), sinus rhythm could be restored by sole pharmacological management in 167 patients (73%). A left ventricular function lower than 55% (OR 3.51 (1.45–8.52)) and prior atrial fibrillation episodes being classified as persistent (OR 2.33 (1.13–4.80)) were significant predictors for non-response to vernakalant. Electrical cardioversion was successful in all patients but one within 196 min (IQR 149–300) of administration of first dosage of vernakalant. No serious adverse events could be observed. 3 patients needed further in-patient care.
Management of recent-onset atrial fibrillation consisting of intravenous vernakalant followed by electrical cardioversion in case of failure appears safe and efficacious. Achieving a rapid conversion, this approach could potentially save resources and costs.
Summary
Background
Mortality data of non-critically ill patients presenting with symptomatic atrial fibrillation to an emergency department are scarce. We aimed to analyze the short-term mortality of ...these patients compared with that of the general Austrian population.
Design/methods
This study analyzed a consecutive series of non-critically ill adults presenting to the emergency department at the Medical University of Vienna between 2012 and 2016 with complaints related to atrial fibrillation. The study outcome was mortality during the observation period. Age-specific and sex-specific mortality rates per 100 person-years were calculated and compared with the mortality rates of the Austrian population during the same period.
Results
In total, 1754 patients with atrial fibrillation (43.1% female) were included in the study. During a median follow-up of 25 months, 248 of these patients died. Observed mortality rates were 7.8 per 100 person-years for females (95% confidence interval, CI 6.6–9.5) and 5.9 per 100 person-years for males (95% CI 5.0–7.1). Age-adjusted and sex-adjusted mortality rates were 2.8 (95% CI 2.3–3.3) and 2.7 (95% CI 2.2–3.2) per 100 person-years, respectively. Mortality rates for the Austrian population were 1.1 per 100 person-years for both females and males. Corresponding standardized mortality ratios were 2.5 for females (95% CI 2.1–3.0) and 2.4 for males (95% CI 2.0–2.9).
Conclusion
The short-term mortality of patients with symptomatic atrial fibrillation presenting to the emergency department was substantially higher compared with the general Austrian population.
Modern diagnostics in emergency medicine Niederdöckl, Jan; Buchtele, Nina; Schwameis, Michael ...
Wiener Klinische Wochenschrift,
03/2021, Letnik:
133, Številka:
5-6
Journal Article
Background and importance
Racial bias is found in both physicians and medical students. Immigrants in many parts of the world face challenges similar to racial minorities. Identification of ...immigrants might however be more subtle than identification by race, and currently, no data are available on a possible bias against the large minority group of migrants in Europe.
Design
Randomized control trial.
Settings and participants
Second-year medical students were randomized into four groups to watch a video of either a male or female patient with pain, with or without immigrant status.
Intervention
Students were asked whether they would administer pain medication (primary outcome).
Outcome measures and analysis
Immigrant status, patient’s gender, student’s gender, age, and language skills were covariates in a logistic regression model. Secondary outcomes included pain medication potency and the student’s rating of the patient’s pain intensity.
Main results
We recruited 607 students 337 females (56%), 387 (64%) between 18 and 22 years old. Analgesia was administered in 95% (n = 576). Immigrant status was not associated with the probability of receiving pain medication 95 vs. 95%, odds ratio (OR) 0.81, 95% confidence interval (CI) 0.39–1.70,
P
= 0.58. Immigrants received high-potency analgesia less often (26 vs. 33%, OR 0.69, 95% CI 0.50–0.96,
P
= 0.03). Female students administered pain medication more frequently (96 vs. 93%, OR 2.29, 95% CI 1.05–5.02,
P
= 0.04), and rated the patients’ pain higher (mean numeric rating scale 7.7, SD 0.9 vs. 7.4, SD 1.0, OR 1.36, 95% CI 1.16–1.60,
P
< 0.001).
Conclusion
Medical students showed no immigration bias with regard to administering pain medication but were less likely to choose high-potency analgesia in immigrants. We also found a gender difference in pain management. These results demonstrate the importance of including knowledge about immigration bias in medical training.
Ibutilide is a rapid-acting antiarrhythmic drug with worldwide use for conversion of recent-onset atrial fibrillation. Vernakalant, approved in the EU in 2010, is likewise used intravenously, with ...proven efficacy and safety compared with placebo and amiodarone in randomized clinical trials. The aim of our study was to compare the time to conversion and the conversion rate within 90 min in patients with recent-onset atrial fibrillation treated with vernakalant or ibutilide.
A randomized controlled trial registered at clinicaltrials.gov (NCT01447862) was performed in 100 patients with recent-onset atrial fibrillation treated at the emergency department of a tertiary care hospital. Patients received up to two short infusions of vernakalant (n = 49; 3 mg/kg followed by 2 mg/kg if necessary) or ibutilide (n = 51; 1 mg followed by another 1 mg if necessary) according to the manufacturer's instructions. Clinical and laboratory variables, adverse events, conversion rates, and time to conversion were recorded. Time to conversion of AF to sinus rhythm was significantly shorter in the vernakalant group compared with the ibutilide group (median time: 10 vs. 26 min, P = 0.01), and likewise the conversion success within 90 min was significantly higher in the vernakalant group (69 vs. 43%, log-rank P = 0.002). No serious adverse events occurred.
Vernakalant was superior to ibutilide in converting recent-onset atrial fibrillation to sinus rhythm in the emergency department setting.
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