Background Over the past 5 years, dabigatran, rivaroxaban and apixaban were approved for stroke prevention. Phase III studies have shown a lower risk of intracranial bleeding with these direct oral ...anticoagulants than with warfarin; however, there is a lack of real-life data to validate this. We analyzed time trends in atraumatic intracranial bleeding from 2009 to 2013 among patients prescribed oral anticoagulants and those not prescribed oral anticoagulants. Methods We used ICD-10-CA (enhanced Canadian version of the 10th revision of the International Statistical Classification of Diseases and Related Health Problems) codes to identify all patients with atraumatic intracranial bleeding who presented to our neurosurgical centre (serving a population of more than 1.2 million). Trained researchers extracted data on anticoagulant medications used in the week before diagnosis of the intracranial bleed. Provincial prescription data for oral anticoagulants were obtained from IMS Brogan CompuScript Market Dynamics. The primary outcome was the time trend in incident intracranial bleeds associated with oral anticoagulation during the period 2009-2013. The secondary outcomes were the time trend in intracranial bleeds not associated with oral anticoagulation and the provincial prescribing patterns for oral anticoagulants during the same period. Results A total of 2050 patients presented with atraumatic intracranial bleeds during the study period. Of the 371 (18%) prescribed an anticoagulant in the week before presentation, 335 were prescribed an oral anticoagulant. There was an increasing time trend in intracranial bleeding associated with oral anticoagulants ( p = 0.009; 6 additional events per year) and in intracranial bleeding not associated with oral anticoagulation ( p = 0.06). During 2013, prescriptions for warfarin decreased to 70% of all oral anticoagulant prescriptions in the province, whereas those for dabigatran and rivaroxaban increased to 17% and 12%, respectively. Interpretation We observed increasing time trends in intracranial bleeding, both associated with and not associated with oral anticoagulants, over the study period. Although aggregate provincial data showed increased prescribing of oral anticoagulants, other more likely explanations for our findings include an aging population or increasing frailty.
Study objective We determine the rate of serious arrhythmias in a cohort of monitored emergency department (ED) chest pain patients and derive a clinical decision rule that can identify which ...patients can safely be taken off continuous cardiac monitoring at initial physician assessment. Methods A secondary analysis of a prospectively collected cohort was completed in a university-affiliated tertiary care center. Consecutive patients with a primary complaint of chest pain who underwent cardiac monitoring in the ED in January to April 2000 were included. Serious arrhythmias were defined as those requiring treatment in the ED. Multivariate recursive partitioning analysis was undertaken to derive a decision rule. Results Nine hundred ninety-two consecutive chest pain patients were monitored in the ED during the study period, of whom 14% and 12% had myocardial infarction and unstable angina, respectively. There were 17 patients (1.7%) with serious arrhythmias detected in the ED. The following decision rule was derived: patients can be removed from cardiac monitoring if they are pain free at the initial physician assessment and have a normal or nonspecific ECG result. The rule had 100% sensitivity (95% confidence interval 80% to 100%) for serious arrhythmias. Applying this rule would have allowed physicians to immediately remove 29% of patients from cardiac monitoring. Conclusion Serious arrhythmias are uncommon in monitored ED chest pain patients. A simple clinical decision rule could be used to safely identify low-risk patients who can be removed from continuous monitoring if its performance is prospectively validated in an independent patient population.
Abstract Introduction The first aim of this study was to investigate the characteristics for elderly patients with acute heart failure presenting to the emergency department. The second aim was to ...determine the characteristics of these elderly patients associated with serious adverse events. Methods The population was divided into two age groups, < 80 and ≥80 years. The primary outcome was the occurrence of a serious adverse event, defined as either death from any cause within 30 days of the index ED visit or any of the following events within 14 days of the index ED visit: admission to a monitored unit, intubation, need for noninvasive ventilation, myocardial infarction, or major procedure; for patients who were discharged after the initial visit, return to the ED resulting in admission to hospital. Results This prospective cohort study included 1658 visits. Older patients had a lower heart rate and higher diastolic blood pressure. The older patients were more likely to experience hospital admission (56% vs. 46%, P < .001). For patients' ≥ 80 years, 109 (14%) experienced a serious adverse event. In this ≥80 years group, history of heart failure, current medication with anti-arrhythmic, acute infarction on the arrival electrocardiography, chest X-ray with pleural effusion, and urea >12 mmol/L were independently associated with short-term serious adverse events. Conclusions Elderly patients with HF are a high risk group. Careful assessment of these factors could help physicians identify those patients most at risk for adverse outcomes and, therefore, most in need of hospital admission.
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