Atrial Fibrillation is the most common cardiac arrhythmia in medical practice.
In 2010, the RACE II trial demonstrated that lenient rate control (resting bpm < 110) in patients with permanent A-fib was just as effective as strict rate control (resting bpm < 80 and < 110 with moderate exercise) in the prevention of major cardiovascular events and hospitalizations for heart failure.
This is a retrospective study designed to evaluate provider adherence to rate control guidelines in patients with A-fib admitted to the adult hospitalist service at an academic medical center, or consults placed to hospitalists from October 2010 – November 2015. Secondary goals were to review charts on a subset of patients to calculate CHA2DS2-VASc scores and to find out whether or not they were discharged on anticoagulation.
Data was extracted from Citrix Powerchart on patients from 17-80 years of age with the diagnosis of permanent atrial fibrillation (ICD 9 427.31) admitted from October 2010 – November 2015. Data was managed with STATA software.
Approximately 75% of patients were maintained at hearts rates < 90 bpm and 50% < 80 bpm. Furthermore, 78% of patients were found to be discharged with ≥ 2 rate control medications. As part of this analysis, Carvedilol, Digoxin, Labetolol and Diltiazem were the most common rate control medications used by UNM hospitalists. At discharge, 50% of patients with CHA2DS2-VASc ≥ 2 were discharged with no anticoagulation.
2014 JACC Executive Summary indicates “a lenient rate-control strategy (resting pulse < 110 bpm) may be reasonable as long as patients remain asymptomatic…” This study serves to remind providers to remain thoughtful of rate control guidelines for inpatients with permanent atrial fibrillation. They are encouraged to allow for less strict rate control while admitted, as the RACE and RACE II trials demonstrated no benefit from this treatment. Additionally, if rate control is necessary, physicians are asked to consider using as few medications as possible to limit side effects, morbidity and ultimately mortality. Finally, providers are also encouraged to spark conversations with patients concerning the appropriateness of anticoagulation if CHA2DS2-VASc ≥ 2.
Future directions for this project include repeating the data analysis every 3-5 years to reassess compliance with guidelines on rate control. To address the results of this study, an improvement may be the design of an electronic medical record application to monitor rate control for inpatients with atrial fibrillation with prompts reminding providers that more or fewer medications are indicated for their patients. Integrated into this same system, prompts could remind providers to consider the need for anticoagulation if appropriate, as part of the final medication reconciliation. Furthermore, initiating a requirement for the hospital pharmacist to review and sign the discharge medication reconciliation list may add an extra means to ensure that patients are being treated with appropriate rate control medications and anticoagulation if indicated.
To cite this abstract:Marquez, F II; Kholwadwala, F; Barrett, E . WHO FIBS ON A-FIB?: RATE CONTROL OF INPATIENTS WITH PERMANENT ATRIAL FIBRILLATION. Abstract published at Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev. Abstract 189. Journal of Hospital Medicine. 2017; 12 (suppl 2). https://www.shmabstracts.com/abstract/who-fibs-on-a-fib-rate-control-of-inpatients-with-permanent-atrial-fibrillation/. Accessed September 17, 2019.