Variation in practice patterns among specialties in the acute management of atrial fibrillation

Ashley M Funk, Keith E Kocher, Jeffrey M Rohde, Brady T West, Thomas C Crawford, James B Froehlich, Sara Saberi, Ashley M Funk, Keith E Kocher, Jeffrey M Rohde, Brady T West, Thomas C Crawford, James B Froehlich, Sara Saberi

Abstract

Background: Atrial fibrillation (AF) is commonly managed by a variety of specialists. Current guidelines differ in their recommendations leading to uncertainty regarding important clinical decisions. We sought to document practice pattern variation among cardiologists, emergency physicians (EP) and hospitalists at a single academic, tertiary-care center.

Methods: A survey was created containing seven clinical scenarios of patients presenting with AF. We analyzed respondent choices regarding rate vs rhythm control, thromboembolic treatment and hospitalization strategies. Finally, we contrasted our findings with a comparable Australasian survey to provide an international reference.

Results: There was a 78% response rate (124 of 158), 37% hospitalists, 31.5% cardiologists, and 31.5% EP. Most respondents chose rate over rhythm control (92.2%; 95% CI, 89.1% - 94.5%) and thromboembolic treatment (67.8%; 95% CI, 63.8% - 71.7%). Compared to both hospitalists and EPs, cardiologists were more likely to choose thromboembolic treatment for new and paroxysmal AF (adjusted OR 2.38; 95% CI, 1.05 - 5.41). They were less likely to favor hospital admission across all types of AF (adjusted OR 0.36; 95% CI, 0.17 - 0.79) but thought cardiology consultation was more important (adjusted OR 1.88, 95% CI, 0.97 - 3.64). Australasian physicians were more aggressive with rhythm control for paroxysmal AF with low CHADS2 score compared to US physicians.

Conclusions: Significant variation exists among specialties in the management of acute AF, likely reflecting a lack of high quality research to direct the provider. Future studies may help to standardize practice leading to decreased rates of hospitalization and overall cost.

Figures

Figure 1
Figure 1
1st choice management options selected by >1%respondents. Stacked bar graph depicting the percentage of each specialty that selected Diltiazem, Esmolol, DCCV, or Metoprolol as 1st line management across all scenarios. NOTE: Other choices in the survey not represented in the graph included: Digoxin, Verapamil, Amiodarone, Ibutilide, Procainamide, Propafenone, and Other. There was a significant difference between specialties regarding 1st choice management across all scenarios, p = 0.032. Abbreviation: DCCV, direct current cardioversion.
Figure 2
Figure 2
Thromboembolic treatment. Bar graph depicting the percentage of each specialty choosing thromboembolic treatment and the percentage that chose bridging in the acute management of AF across scenarios 1–5. There was a significant difference between specialties regarding the decision to use thromboembolic treatment, p = 0.014 as well as the decision to bridge, p < 0.001. NOTE: Abbreviation: AF, atrial fibrillation.
Figure 3
Figure 3
Likelihood to Admit and Need for Cardiology Consultation.a: Likelihood to Admit. Bar graph comparing percentages of likelihood to admit in scenarios of new vs paroxysmal vs chronic AF. There was a significant difference in admitting practices between specialties for paroxysmal AF (p < 0.044). Abbreviation: AF, atrial fibrillation. b: Need for Cardiology Consultation. Bar graph comparing the percentage of each specialty that thought a cardiology consult would be necessary for scenarios of new vs paroxysmal vs chronic AF. There was a significant difference in need for consultation between specialties for new onset AF (p = 0.023). Abbreviation: AF, atrial fibrillation.
Figure 4
Figure 4
AustralasianversusUS Comparison of Rate vs. Rhythm Control Strategies in Paroxysmal AF < 48 hours with Low CHADS2 Score. Bar graph comparing percentages of rate vs rhythm control as 1st line management for a scenario of paroxysmal AF with symptoms <48 hours and low CHADS2 score. Australasian cardiologists and EPs were more aggressive with rhythm control strategies as compared with US counterparts. Abbreviations: AF, atrial fibrillation; EP, emergency medicine physicians; US, United States.
Figure 5
Figure 5
Australasian versus US comparison in thromboembolic treatment decisions. a: Australasian versus US Comparison in Thromboembolic Treatment Decisions for Scenarios of Paroxysmal AF < 48 hours with Low CHADS2 Score. US cardiologists more often chose no thromboembolic treatment, fewer used aspirin, and more selected heparin or other strategies compared to their Australasian counterparts. The category “Other” included Australasian survey responses of clopidogrel, US responses of dabigatran and rivaroxaban, as well as, write-in responses in both surveys. Abbreviations: AF, atrial fibrillation; EP, emergency medicine physicians; US, United States. b: Australasian versus US Comparison in Thromboembolic Treatment Decisions for Scenarios of New Onset AF ≥ 48 hours with Low CHADS2 Score. There were significant differences among both physician groups. US cardiologists chose no thromboembolic treatment and heparin more often, and used aspirin and warfarin alone less often than their Australasian colleagues. US EPs more often selected not to use thromboembolic treatment compared to their Australasian counterparts, and selected aspirin and heparin less frequently. Abbreviations: AF, atrial fibrillation; EP, emergency medicine physicians; US, United States.

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