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Prehospital Rate / Rhythm Control Interventions Improve Outcomes for Patients Presenting in Atrial Fibrillation with Rapid Ventricular Respons

Author: Christine O’Neil, MEd, NRP | |

Associate Authors:

Introduction

There is little evidence regarding prehospital rate and rhythm control interventions for patients with atrial fibrillation who present with rapid ventricular response (AfRVR). The purpose of this study was to compare emergency department (ED)
and hospital outcomes for patients presenting to EMS with AfRVR who do and do not receive prehospital rate or rhythm
control intervention.

Methods

This retrospective cohort study used the calendar year 2021 ESO Research Collaborative (Austin, TX) dataset to identify 9-
1-1 scene responses for patients ages 16 to 100 years presenting with AfRVR (i.e., initial EKG = atrial fibrillation AND initial heart rate ≥ 110). Rate or rhythm control interventions included vagal maneuvers, medications (e.g., diltiazem, verapamil, propranolol, etc.), or electrical cardioversion. Our primary outcome measure was ED discharge to home; secondary outcomes included hospital length of stay (LOS) for admitted patients, and ED/hospital mortality. We used propensity score matching to compare outcomes among intervention and nonintervention patients with similar demographics, clinical characteristics, and comorbidities. We report the adjusted difference in outcomes and number needed to treat (NNT), along with 95% confidence intervals.

Results

There were 10,234 eligible patients presenting with AfRVR who had ED and hospital outcome data available; after propensity matching, 8832 patients were retained in the analysis: 1376 (15.6%) with prehospital intervention, and 7456 (84.4%) similar patients without intervention. ED discharge to home occurred for 37.4% of the intervention patients vs 28.9% of the nonintervention patients (adjusted difference: +7.6%, CI: +3.6%; +11.6%; NNT: 14, CI: 9; 28). Among admitted patients, median (IQR) LOS was 4 (2-7) days for intervention patients vs 5 (3-8) days for nonintervention patients (adjusted difference: –0.7 days, CI: –1.3; –0.1). Mortality among intervention patients was 3.9% vs 7.2% for nonintervention patients (adjusted difference: –2.9%, CI: –4.8%; –1.0%; NNT: 35, CI: 21-100).

Conclusion

Among propensity score matched AfRVR patients with similar demographic, clinical and comorbidity profiles, prehospital rate or rhythm control interventions were associated with increased likelihood of ED discharge to home (NNT = 14); shorter hospital length of stay for admitted patients (~ 1 day); and reduced overall mortality (NNT = 35).