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ERs Can Prevent Emergencies, Too

It's a place to identify people at risk of stroke

THURSDAY, Oct. 31, 2002 (HealthDayNews) -- A hospital emergency room can be a great place to head off an emergency in addition to treating whatever problem brings someone there, a study finds.

The emergency in the making is a stroke caused by the irregular heartbeat called atrial fibrillation, and records of more than 78,000 visits show that the emergency room is a prime location to identify people with the problem and start them on preventive treatment, says a report in tomorrow's issue of Stroke.

"The basic lesson of the study is that in the United States we are tremendously under-treating atrial fibrillation with proven therapies to reduce stroke risk, and that these patients may be easily identified as they flow through the emergency room system," says Dr. Phillip A. Scott, an assistant professor of emergency medicine at the University of Michigan Health System and lead author of the report.

People with atrial fibrillation or other heart rhythm problems are more likely than others in the general population to require emergency treatment, the study finds. The overall incidence of atrial fibrillation among ER patients in the study who had electrocardiograms was 1.1 percent, about a fifth higher than the estimated general prevalence. Many of those people whose atrial fibrillation had been previously identified were not taking the drug most effective at reducing stroke risk.

That drug is warfarin, best known by the brand name Coumadin, an anticoagulant that can prevent a blood clot that can cause a stroke. Only 55 percent of the people who were eligible for warfarin were taking the drug, Scott says.

"Current computer models estimate that we could prevent 40,000 strokes each year if we were able to get all eligible patients on appropriate medication," he says. However, he quickly adds that reaching that goal would require a basic change of attitude about emergency room function.

"Right now, emergency physicians have not been expected or trained to evaluate patients for preventive medical therapy," Scott says. "What we have to do is identify how emergency physicians can single out these patients and then intervene to increase the use of anticoagulants such as warfarin."

It won't be easy, Scott says, since emergency rooms now are staggering under a burden of more than 100 million patient visits a year, a number increasing by 6 percent to 8 percent annually. But "there are methods to intervene that require little or no time," he says. People can help by doing something as simple as taking a pulse; an irregular beat can be an indicator of atrial fibrillation.

Emergency rooms are "overworked, understaffed and overwhelmed," says Dr. Larry B. Goldstein, a professor of medicine at Duke University Medical Center and a spokesman for the American Stroke Association, but they are nevertheless one of the few places where the undiscovered problems of many Americans can be identified.

"About 40 percent of Americans don't have a primary-care physician, so the only time they interact with the medical care system is in the emergency room," Goldstein says. He sees that interaction as an opportunity to intervene in a variety of problems -- "not only atrial fibrillation, but also high blood pressure, obesity, cigarette smoking and other general lifestyle factors that are amenable to modification before they go on to heart attack or stroke."

Can that happen? Maybe, Goldstein says, "if the proper programs are put into place and supported. There is the potential to give a consistent message of good health practices."

What To Do

You can learn more about atrial fibrillation, its dangers and treatment, from the American Heart Association. Get a primer on brain attacks from an affiliated site, the American Stroke Association.

SOURCES: Phillip A. Scott, M.D., assistant professor, emergency medicine, University of Michigan Health System, Ann Arbor; Larry B. Goldstein, M.D., professor, medicine, Duke University Medical Cancer, Durham, N.C.; Nov. 1, 2002, Stroke
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