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ABSTRACT & COMMENTARY
By Edward P. Gerstenfeld, MD
Professor of Medicine, Chief, Cardiac Electrophysiology, University of California, San Francisco
SOURCE: Patel NJ, et al. Contemporary trends of hospitalization for atrial fibrillation in the United States, 2000 through 2010: Implications for healthcare planning. Circulation 2014;129:2371-2379.
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and has been the leading arrhythmic cause for hospitalization. With an increasing trend toward outpatient care of subacute illness, it is possible that the AF hospitalization rate is stable or decreasing despite the aging population. This study identified AF-related hospitalizations during the years 2000-2010 using CPT code 427.31 as the principal discharge diagnosis. Overall AF hospitalizations increased by 23% from 2000 to 2010. The most frequent coexisting conditions were hypertension (60.0%), diabetes mellitus (21.5%), and chronic pulmonary disease (20.0%). Overall in-hospital mortality was 1%. In-hospital mortality rate decreased significantly from 1.2% in 2000 to 0.9% in 2010 (29.2% decrease; P < 0.001). The mean cost of AF hospitalization increased significantly from $6410 in 2001 to $8439 in 2010 (24.0% increase; P < 0.001). The authors concluded that hospitalization rates for AF have increased exponentially among U.S. adults from 2000 to 2010, as have the costs to care for these patients.
AF remains the most common cardiac arrhythmia, and makes up a large part of any outpatient cardiology practice. Management consists of ventricular rate control, stroke prophylaxis, and, if symptomatic, restoration and maintenance of sinus rhythm. Yet it is rare that AF episodes, even new-onset AF, require acute hospitalization. Newer anticoagulants, including Factor Xa inhibitors or direct thrombin inhibitors, can be started orally and reach therapeutic effect in 1-2 hours. Ventricular rate control can often be achieved with oral beta-blockers or calcium-channel blockers quickly. Myocardial ischemia, acute coronary syndrome, or pulmonary embolus are rarely causes of AF. Most AF patients can be evaluated, treated, and discharged from an emergency department (ED) or managed in an outpatient clinic. The 23% increase in AF hospitalization from 2000 and 2010 is striking and represents a potential crisis in health care dollars. AF ablation is becoming more common, but these procedures are typically performed as outpatient procedures and should not be contributing to the increase in hospitalizations. How do we deal with this crisis moving forward? It is unlikely that ED physicians will have the expertise to manage AF on an outpatient basis. Many hospitals have established chest pain centers to deal efficiently with patients presenting with chest pain and allow rapid evaluation and discharge. General cardiologists will have to take an active role in evaluating and treating AF patients in the ED in order to reverse this trend, which will otherwise only increase as the population continues to age. Perhaps we should be considering "AF centers" or programs to allow these patients to be rapidly evaluated and treated in the ED by cardiologists. Such a study examining the cost effectiveness of cardiology-driven AF treatment in the ED would be of great interest.