Medical Doctor University College Dublin Ireland
Dr. Nicola Fortune is a Medical Doctor who specializes in General Practice with a special interest in cardiology, specifically in the optimal treatment of atrial fibrillation. Her previous research ‘Clinical Outcome and prognosis of patients with acute pulmonary oedema and congestive cardiac failure’ was presented at the European Society of Cardiology Heart Failure conference 2018 in Vienna.
Dr. Fortune is an experienced Doctor and keen clinician who is a graduate of University College Dublin (UCD) medical school.
The majority of her medical practice has been at University-teaching hospitals in Ireland including St James University Hospital, Dublin, Our Lady of Lourdes Hospital, Drogheda and Cavan General Hospital.
Dr. Fortune has a wide range of international medical experience having previously worked in Fiona Stanley Hospital and Sir Charles Gardiner Hospital in Perth, Australia. She has also lived and directed a humanitarian medical-aid project in St Luke’s Mission Hospital in Mpanshya, Zambia.
Atrial fibrillation is a very common clinical problem. Often it is a frequent cause of hospitalization for the patient admitted via the emergency department or through the acute medical assessment unit. There common symptoms of presentations are palpitation, dyspnea, chest pain, dizziness etc. These patients are often treated optimally with appropriate anticoagulants and heart rate control therapy. Eventually, they underwent electrical cardioversion (DCCV). Despite of appropriate treatment regimen, a patient has a recurrence of atrial fibrillation. A very little is known about the medical comorbidities and function status of these patients. There is therefore an important paucity of the data indicating the prognosis, recurrence and failure or success of electrical DCCV
We sought to investigate the determinants of successful cardioversion in the selective group of patients who were admitted electively for electrical cardioversion (DCCV) in Our Lady of Lourdes hospital last six months i;e from 1st Jan 2017 to 30th June 2017.
We audited the charts of the patient admitted electively for electrical cardioversion in our coronary care unit at Our Lady of Lourdes Hospital. Total of 58 patient had undergone electrical cardioversion during our study period in the last six months, i:e from January 2017 to June 2017. We retrospectively reviewed the case notes of all those patients with atrial fibrillation. Variable used were age, gender, medical comorbidities such as Hypertension, diabetes, Chronic obstructive pulmonary disease, Chronic kidney disease, anemia, ischemic heart disease, cerebrovascular accident or transient ischemic attacks. We calculated CHA2DS VASC score, HAS Bled Score. We looked through their echo study in detail including their ejection function, Left atrial size, Right ventricular dysfunction, any significant valvular disease.
A total of 58 patient’s charts were studied (40 were males and 18 were females) With age group 45yrs -55yrs (12males, 1 female) 55yrs -65yrs (6males, 1female) 65yrs -75yrs (10males, 9 females) 75yrs -85yrs (13males, 7 females) (fig 1). Their comorbidities were recorded. The commonest medical comorbidity was hypertension 68.9% (n40), followed by obesity 39.6%(n23) and then ischemic heart disease 22.41%(n13). Chronic obstructive pulmonary disease in 12.06%(n7). Other less frequent medical comorbidities were diabetes and chronic kidney disease, which has the equal prevalence of 6.89%(n4). Anemia and cerebrovascular accident or transient ischemic attacks were noted in 3.44% and 1.7% patients respectively. CHA2DS VASC Score was recorded in all patients. Likewise, a HAS-BLED score was also charted. Very detailed echocardiogram findings were charted as below. Ejection function of 20-30% was noted in 6 patients, 35-45% in 5 patients, 45-55% in 15 patients and >55% in 27 patients. Echo was not done in 5 patients and limited quality images noted in 2 patients. The left atrial size was reported to be normal in 21 patients (<3.8cm). 12 patients have mild enlargement of the left atrium (4.0-4.5 cm) and 8 and 8 patients have moderately enlarged (4.6-5.0 cm) and severely enlarged (>5.0cm) left atrium respectively. In 9 patient left atrium size cannot be assessed accurately.
The outlook of electrical cardioversion in treatment of atrial fibrillation in the present era remains substantial. There are no historical data available to report on individual determinants of success of electrical cardioversion. In our study we found that normal left atrial size is an independent decisive factor in successful restoration of sinus rhythm from atrial fibrillation followed by optimal blood pressure control (SBP <150 mmhg) and obesity respectively. In another subset of this observational study, we also noted that two or more than two medical comorbidities with moderately enlarged left atrium will have difficulty in restoration of sinus rhythm with electrical cardioversion.
Each patient involved in this study was selected based on criteria identified with in the admission unit. There may be a possibility of selection bias. Patients are assessed in the cardiology clinic or Acute medical assessment unit by our team doctor, if found suitable then will be listed for elective cardioversion. Though, our centre is a district general hospital. However, this is not the only one. There are few other district hospitals in the surrounding vicinity in Drogheda, within close proximity to our catchment area. This may skew the population that attended our emergency services, cardiology services or acute medical assessment unit services. Some patient may seek health care elsewhere. Nonetheless, we believe our sample to be reasonably sizeable and more representative sample could only be achieved, should a disease registry to be established.