PACUPod is your trusted source for AI-infused evidence-based insights tailored to advanced clinical pharmacists and physicians. Each episode dives into the latest primary literature, covering medication-focused studies across emergency medicine and critical care. We break down study designs, highlight key findings, and objectively discuss clinical implications—without the hype—so you stay informed and ready to apply new evidence in practice. Whether you’re preparing for board certification or striving for excellence in patient care, PACUPod helps you make sense of the data, one study at a time.
Britany: Welcome back to PACULit. Today, we’re discussing a study on opportunistic atrial fibrillation (AF) screening using continuous ECG monitoring in the emergency department (ED). Seth, AF remains a challenge, especially with paroxysmal or asymptomatic cases, right?
Seth: Absolutely. AF increases ischemic stroke risk fivefold, yet many remain undiagnosed until complications arise. The ED, with its high patient volume and cardiovascular risk, is an untapped opportunity for screening.
Britany: The study by Bismuth et al. addresses continuous ECG monitoring in the ED—a setting not extensively studied before. While continuous monitoring improves AF detection elsewhere, its yield and impact in the ED were unclear.
Seth: The study also highlights demographics of undiagnosed AF patients in the ED—beyond older adults, it includes underserved groups like Medicaid recipients and racial/ethnic minorities, pointing to disparities in primary care access and the ED’s potential role in screening.
Britany: Exactly. The ED can be a critical touchpoint for chronic disease detection, especially for those with limited outpatient follow-up. This study underscores missed stroke prevention opportunities when AF goes undetected.
Seth: Timing is perfect with the 2024 ESC guidelines endorsing opportunistic AF screening. This study provides real-world data supporting continuous ECG monitoring in the ED and clarifies how many identified patients meet anticoagulation criteria.
Britany: On study design: it was a retrospective cohort at a single academic ED from August 2020 to January 2024, analyzing over 65,000 adults undergoing continuous ECG monitoring during their ED stay—a massive sample.
Seth: Inclusion was adults 18+ receiving continuous ECG monitoring, excluding those with known AF to focus on new diagnoses, strengthening validity on undiagnosed AF prevalence.
Britany: The intervention was opportunistic AF detection via continuous ECG during the ED stay. Comparator groups included patients without AF detected and those with known AF, allowing outcome comparisons.
Seth: Primary outcome: proportion discharged with newly diagnosed AF. Secondary outcomes: proportion meeting anticoagulation criteria by CHA2DS2-VASc and ischemic stroke incidence post-discharge through August 2024. They used Cox models for adjusted stroke risk.
Britany: Their subgroup analyses by demographics and insurance status add clinical relevance, especially for pharmacists and physicians working with diverse populations.
Seth: Key findings: 3% (1,945/65,244) were discharged with previously undiagnosed AF; 71.2% met anticoagulation criteria—a significant number for stroke prevention.
Britany: The undiagnosed AF group was younger (median 72 vs. 79), had more females (49.6% vs. 43.7%), and greater Medicaid and Black/Hispanic representation, highlighting healthcare disparities.
Seth: This suggests continuous ECG monitoring in the ED uncovers AF in populations missed by outpatient screening and raises questions on integrating screening into ED workflow.
Britany: Stroke risk was notable: undiagnosed AF patients had 2.6 ischemic strokes per 100 person-years. Adjusted hazard ratio (HR) for stroke vs. no AF was 3.00; vs. known AF, HR was 1.32—still elevated.
Seth: This supports early detection and anticoagulation, though causality isn’t definitive due to retrospective design. Also, post-discharge anticoagulation initiation rates weren’t fully captured—a limitation.
Britany: This aligns with the LOOP trial, which found increased AF detection with implantable monitors but no significant stroke reduction. Detection alone isn’t enough; timely anticoagulation and follow-up are essential.
Seth: From a pharmacist’s view, this reinforces advocating for protocols linking ED AF detection with outpatient management. Pharmacists play key roles in medication reconciliation, education, and anticoagulation monitoring.
Britany: The higher Medicaid and minority representation in undiagnosed AF highlights the need for culturally competent care and addressing anticoagulation adherence barriers.
Seth: Another clinical pearl: watch for drug interactions in anticoagulated patients detected via ED screening—many may be on amiodarone or other antiarrhythmics interacting with DOACs. Monitoring is vital.
Britany: Renal function is also crucial. Many older adults with AF have chronic kidney disease affecting DOAC dosing. The ED offers a chance to assess renal function and optimize therapy early.
Seth: The study’s use of continuous ECG monitoring rather than intermittent checks is key. Paroxysmal AF can be missed on standard ECGs; continuous monitoring improves detection, especially for asymptomatic episodes.
Britany: Like the Hillmann et al. study using 14-day Holter monitoring in high-risk patients, which found 14% AF detection and 90% anticoagulation initiation. Longer monitoring improves detection and treatment.
Seth: But the ED usually involves shorter monitoring. This study shows even typical ED stays with continuous ECG can identify many undiagnosed AF cases.
Britany: It’s about efficiently leveraging existing resources. Many ED patients already have continuous ECG monitoring for other reasons, so adding opportunistic AF screening requires minimal extra infrastructure.
Seth: The single-center academic ED design may limit generalizability, but the large, diverse sample strengthens applicability.
Britany: Seth, how might this study influence practice or research?
Seth: It supports incorporating opportunistic AF screening in EDs, especially for older and underserved patients. Future prospective studies should assess if screening reduces stroke and evaluate cost-effectiveness.
Britany: Integrating pharmacists into ED teams to facilitate anticoagulation initiation and follow-up could improve outcomes. Education on drug interactions and adherence support is vital.
Seth: Randomized controlled trials comparing continuous ECG monitoring in the ED versus usual care would help confirm benefits.
Britany: To summarize, Bismuth et al. highlight the ED as a promising setting for opportunistic AF screening via continuous ECG monitoring, identifying many high-stroke-risk patients, especially among underserved groups.
Seth: Detection is the first step, opening doors for timely anticoagulation and stroke prevention. Pharmacists and physicians should advocate for protocols integrating screening with comprehensive follow-up.
Britany: Thanks for the great discussion, Seth. And thanks to our listeners for tuning into PACULit. Stay curious, stay informed, and keep advancing patient care with evidence-based practice.
Seth: Thanks, Britany. Looking forward to our next update. Take care!