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Antiarrhythmic Drugs and Electrical Cardioversion for Conversion to Sinus Rhythm KQ 4: What are the comparative safety and effectiveness of available antiarrhythmic agents and electrical cardioversion for conversion of atrial fibrillation to sinus rhythm? Do the comparative safety and effectiveness of these therapies differ among specific patient subgroups of interest? Key Points • Based on 4 RCTs (2 good viagra gold 800mg generic, 2 fair quality) involving 411 patients cheap 800mg viagra gold with visa, use of a single biphasic waveform is more effective in restoring sinus rhythm than use of a single monophasic waveform in patients with persistent AF (high strength of evidence) order 800mg viagra gold free shipping. Description of Included Studies A total of 42 RCTs involving 5,780 patients were identified that assessed the use of antiarrhythmic drugs or electrical cardioversion for the conversion of AF to sinus rhythm 140,170-181 (Appendix Table F-4). Thirteen studies were considered to be of good quality, 27 of fair 144,145,147,149,182-204 205,206 quality, and 2 of poor quality. The studies were published from the years 170,171,188,196 2000 through 2011; however, all but four studies were published in 2007 or earlier. Only 7 studies included sites in the United States; 25 140,144,145,147,170,175-179,187,188,191-196,200-206 included sites in Europe. The study population consisted 144,145,147,170-172,175-178,183,185-187,192-195,197-199,202- entirely of patients with persistent AF in 25 studies, 204,206 189 entirely of patients with paroxysmal AF in 1 study, and entirely of patients for whom 174,195 prior rate- or rhythm-control therapy had been ineffective in 2 studies. Funding was unclear 140,144,147,170,172,173,175,179,181,183,185-188,190-206 or not reported in 31 studies. Seven studies used 145,171,174,176,178,180,184 industry funding, none was government-only funded, and eight were funded 145,149,171,174,177,178,182,189 by nongovernment/nonindustry sources. In the majority of studies, the 145,179,181,183-187,193,195,197-203,206 setting was not reported (18 studies ). Of the remaining studies, 7 140,144,174,177,182,191,205 149,170,173,189,190 were inpatient, 5 were in the emergency room, 10 were 147,171,172,175,176,178,180,192,194,204 188,196 outpatient, and 2 were in more than one setting. Figure 5 represents the treatment comparisons evaluated for this KQ. Overview of treatment comparisons evaluated for KQ 4 aLines running from one oval back to the same oval (e. Abbreviations: KQ=Key Question; J=Joules; Tx=treatment Twenty-one studies compared methods of external electrical cardioversion, four studies 178 199,205 compared electrical cardioversion augmented by medications (metoprolol, verapamil, 195 and ibutilide ) with electrical cardioversion alone, and eight studies evaluated the efficacy of drugs used both prior to and after external electrical cardioversion (amiodarone [five 144,149,180,181,204 144,204 145,147,149,204,206 studies ], diltiazem [two studies ], digoxin [five studies ], 145,147,206 149,180,181 verapamil [three studies, ], sotalol [three studies ]). Nine studies compared drugs 140,170,177,188-193 without (or prior to) external electrical cardioversion. No study compared electrical cardioversion directly with pharmacological cardioversion. Of the 42 studies, 3 had a 170,180,193 181,192 placebo arm, and 2 had a “control” arm that was not included in this review. The remaining 36 studies had 2 intervention arms each. The primary outcome reported for this KQ was restoration of sinus of rhythm within a specified time period following the intervention. This time period ranged from immediately following the intervention to 6 weeks following the intervention. Several studies presented outcome data at multiple time points following the intervention, while others assessed time to outcome within a prespecified time frame. Only three studies did not report restoration of sinus 194,199,205 rhythm. Of these, one assessed maintenance of sinus rhythm at 1 week following 199 electrical cardioversion or verapamil plus electrical cardioversion, another reported 42 194 maintenance of sinus rhythm 1 month after electrical cardioversion, and the third reported recurrence of AF within 1 week following verapamil with electrical cardioversion versus 205 electrical cardioversion alone. Three studies reported an outcome relevant to this KQ in addition to restoration of sinus rhythm. One study reported all-cause mortality, mixed embolic events, and maintenance of sinus 185 191 rhythm at 6 weeks; one reported recurrence of AF within 24 hours after cardioversion; and 202 one reported recurrence of AF within 1 minute of electrical cardioversion. Detailed Synthesis Comparisons of Various Methods for External Electrical Cardioversion Overview Twenty-one studies (2,996 patients) compared different methods of external electrical cardioversion. Nine studies (1,219 patients) compared a biphasic waveform with a monophasic waveform (Table 10), and 4 studies (393 patients) compared anterolateral versus anteroposterior positioning of the defibrillation electrodes (paddles in 2 studies, paddles and/or gel pads in 1 175,183,187,202 study, and pads in 1 study). Three studies (432 patients) included a comparison of an 172,185,186 initial 200 J shock with an initial 360 J shock. The remaining five studies addressed 197 182 comparisons in polarity (one study ), shapes of the biphasic waveform (one study ), 176 composition of the cardioversion electrodes (one study ), and different amounts of energy 171,198 delivered (two studies ). Among the 9 studies comparing a biphasic waveform with a monophasic waveform, 8 assessed restoration of sinus rhythm at 0 or 30 minutes after cardioversion, and 1 assessed 194 maintenance of sinus rhythm at 1 month following electrical cardioversion. Only two studies 194,203 included only patients with persistent AF, and one study included only patients for whom a 174 prior rate- or rhythm-control therapy was ineffecitve. One study also included an assessment 203 of recurrence of AF within 1 minute following initial cardioversion.

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In brief discount 800 mg viagra gold mastercard, the introduction of PRISM increased emergency episodes purchase 800 mg viagra gold free shipping, hospital admissions and costs across the population and at each risk level without clear evidence of benefits to patients safe 800mg viagra gold. Evaluate the alternative approach of delivering different services to different levels of risk, rather than the current focus on the very highest level of risk. Investigate the effects of emergency admission risk stratification tools on vulnerable populations and health inequalities. Conduct a secondary analysis of the Predictive Risk Stratification: A Trial in Chronic Conditions Management data set by condition type. Explore the acceptability of predictive risk stratification and communication of risk scores to patients and practitioners. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals xxv provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. SCIENTIFIC SUMMARY Trial and study registration The trial is registered as ISRCTN55538212 and the study is registered as PROSPERO CRD42015016874. Funding Funding for this study was provided by the Health Services and Delivery Research programme of the National Institute for Health Research. A recent Health Foundation and Nuffield Trust report estimates that up to one in five emergency admissions are avoidable,10 especially where they relate to ambulatory care-sensitive conditions – conditions amenable to community prevention. Recent analysis in England suggests that better management of ambulatory care could achieve yearly savings of > £1. In England and Wales, > 16 million people have a long-term (or chronic) condition – and their care accounts for 70% of expenditure on health and social care. They shared key features of early identification and response to patient needs, joined-up care, and holistic support centred on the person rather than on specific conditions. Both models championed risk profiling as a means of identifying patients at risk (case finding) who may benefit from proactive management. The English model included systematic risk profiling as one of three primary drivers for the model, alongside integrated locality teams and systematised support for patients to manage themselves. This proactive targeting of services at people at defined risk has retained prominence in UK Government policy ever since, notably within efforts to introduce integrated care. The approach is based on proactive targeting and support for those at risk, with the aim of preventing health deterioration and emergency admissions to hospital. To be cost-effective, however, preventative interventions must use case-finding techniques that target those 3 15 18, , at risk. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 1 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. INTRODUCTION Identifying those at risk A number of approaches to identifying patients at risk have been explored. One approach is to ask clinicians to select at-risk patients based on their knowledge and experience, but a study by Allaudeen et al. An alternative is to use a criteria-based approach, whereby individuals meeting certain conditions are selected for intervention. For example, in the UK Evercare pilots, in nine English primary care trusts (PCTs), patients aged ≥ 65 years with two or more emergency admissions in the previous year were eligible for case management by community matrons. The intervention did not show an effect, however, with the accuracy of the approach to identifying patients at risk criticised. The resulting clinical prediction models are intended to help clinicians make better decisions by providing more objective 2324, estimates of probability as a supplement to other clinical information. Building on the successful implementation of risk models predicting diabetes mellitus (e. QDiabetes®) and cardiovascular disease (Framingham Risk Score25), emergency admission risk prediction (EARP) models have been widely developed – Table 1 provides examples. In calculating individualised risk for a given population, the models use data from up to three sources: self-reported data from patients; routinely collected administrative data; and data from the clinical record or other primary data source. Those models that performed best (in terms of predictive accuracy, as measured by c-statistics of > 0. These better-performing models all used routinely collected clinical patient data rather than self-reported patient data, and it is recognised that models reliant on self-reported (questionnaire) data are limited by response rates, recall issues and respondent burden. A 2015 NHS England paper on the Next Steps for Risk Stratification in the NHS recognised the need for robust evidence, and a pressing need for further research and evaluation, using high-quality study designs. The review confirms that the most common intervention used in emergency admission avoidance are various forms of case management. Although definitions of case management vary, Hutt et al. Case management often covers a range of activities, but it is recognised that these can vary widely between programmes.

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