Early Arrhythmia-Specialist Consult, Ordered in the ER, a Boon to AF Outcomes: ER2EP Study

May 02, 2022

A tweak to the usual way patients with atrial fibrillation (AF) are handled in the emergency room could improve outcomes like death or hospitalization, suggests a new study that some see as a model for care-delivery settings beyond the ER.

Half of patients with new-onset AF in the study were managed in the ER on a care pathway calling for electrophysiology (EP) consultation early in the process, indeed almost right away. The other half went to different ERs in the same hospital system and received standard care without any EP consult requirement.

The early-consult group was treated with ablation, antiarrhythmics, and oral anticoagulation weeks sooner than those who followed a standard pathway in the ER. The intervention was associated with better survival and these patients were less likely later to revisit the ER or be hospitalized, investigators reported.

The findings suggest "a single intervention of appropriate electrophysiologic consultation that is directed from the emergency room" would lead to better outcomes, in part by "mitigating the inherent hurdles in navigating patients through a very complex healthcare system," said Dhanunjaya R. Lakkireddy, MD, Kansas City Heart Rhythm Institute, Overland Park, Kansas.

It therefore would probably also cut associated costs, said Lakkireddy, who presented the ER2EP study primary results April 29 at the Heart Rhythm Society (HRS) 2022 Scientific Sessions, held virtually and live in San Francisco.

The median time from ER evaluation to consultation with an EP specialist was about 1 day for patients in the early-consult arm compared with 128 days for those managed on a standard pathway, Lakkireddy told theheart.org | Medscape Cardiology.

It demonstrates that "a very simple intervention that is relatively non–labor-intensive can open up an opportunity for patients to get faster and improved care, thereby impacting short-term as well as the long-term outcomes, and really bringing in a paradigm shift in the way we can tackle atrial fibrillation."

That, Lakkireddy said, "is something that would be extremely important for healthcare systems to recognize and consider" in efforts to deliver expeditious care and improve outcomes.

"I think this is a perfect opportunity for medical systems," agreed Gregory M. Marcus, MD, MAS, University of California, San Francisco. "Payers would almost certainly benefit because given the consequent reduction in healthcare utilization, this is likely not only very cost efficient, but cost savings," he told theheart.org | Medscape Cardiology.

The study's intervention would be "quite feasible" in practice, Marcus said, as the invited discussant following Lakkireddy's presentation. "There's no clear reason that implementing this would be especially arduous or costly. It's just an issue of setting up the system" between ER physicians and EP specialists.

"I would suspect that ER doctors would be delighted to have this sort of access," Marcus said. "It really is a kind of win-win."

The ER physicians participating in ER2EP were very receptive to engaging EP specialists early in the process, Lakkireddy agreed. They were glad, once the patients were triaged, stabilized, and given acute care, "to pass the baton on to somebody else, knowing that a specialist who actually knows a lot about the disease can actually make a definite difference in providing better access to therapeutic options," he observed.

The registry study prospectively enrolled 400 patients with a primary diagnosis of new-onset AF who presented to emergency departments in a single hospital system from 2019-2021; about half (48%) were women.

Half the group presented to ERs providing standard care that did not necessarily call for EP-specialist consultations. The other 200 patients went to ERs incorporating the ER2EP intervention in the AF care pathway, Lakkireddy reported. All ERs in the study and their associated hospitals shared one electrophysiology service and so relied on the same specialists for consultations.

Patients with AF who required admission would see an EP specialist on duty at the hospital; ER physicians ordered the consult by entering it into the electronic medical record. Patients who could be discharged from the ER were evaluated by specialists as outpatients. The ER physicians simply faxed the referral to the EP clinic, Lakkireddy said, "and then the clinic was basically asked to get the patients in relatively quickly."

Patients presenting to ER2EP centers fared strikingly better over 12 months for all three parts of the primary endpoint: time to initiation of therapy with ablation, oral antiarrhythmic therapy (AAD), and oral anticoagulation (OAC).

Table. Mean Time to Definitive Therapy for New Onset AF, ER2ED Primary Outcomes

Endpoint Early EP Consult Standard Care P value
Time to Ablation 52.8 days 180.6 days < .001
Time to AAD Therapy 2.6 days 25 days < .001
Time to OAC Initiation 1.7 days 17 days .002


The intervention group also had a shorter mean length of stay (2.4 vs 5.8 days), fewer returns to the ER for "heart-related issues" (9 vs 20 visits), and on average fewer hospitalizations (0.97 vs 1.46 admissions) compared with the standard-care group (P < .001 for all 3 differences).

But the groups didn't differ significantly with respect to stroke or bleeding complications.

The study was "innovative in that it really opens the door to thinking about many other similar opportunities," Marcus said.

For example, he said, "We can think about extrapolating this further to clinics — general medicine clinics, cardiology clinics — where no doubt there are many patients suffering from nonischemic cardiomyopathy just because they haven't had the opportunity to meet up with an electrophysiologist who can relieve them of their frequent PVCs [premature ventricular contractions] or their chronic RV [right ventricular] pacing."

ER2EP was funded by Biosense-Webster. Lakkireddy discloses receiving research grants from Medtronic, Atricure, and Biosense-Webster; consulting or serving as an advisor for Medtronic, Abbott Medical, Boston Scientific, Atricure, Acutus, Cardiovia, AltaThera, AME, Phillips, and Biosense-Webster; and serving on a speakers bureau for Boston Scientific, Biosense Webster, and Janssen Pharmaceuticals. Marcus discloses owning stock in InCarda Therapeutics; receiving honoraria or fees for speaking or consulting from Johnson & Johnson and InCarda Therapeutics; and receiving research grants from Medtronic and Baylis Medical.

Heart Rhythm Society 2022 Scientific Sessions. Abstract LB-735-02 - Clinical and Economic Impact of an Organized Treatment Pathway on Atrial Fibrillation Patient from the Emergency Room to Electrophysiology Service (ER2EP Study). Presented April 29, 2022.

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