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Background Atrial Fibrillation (AF) and Heart Failure (HF) frequently co-exist conferring considerable morbidity and mortality, yet current treatment options remain limited. Recent meta-analyses of patients with concomitant AF and HF have suggested no prognostic benefit of beta-blockers or digoxin, creating a paradox whereby those most in need have the fewest therapeutic choices. We sought to investigate the association between HF and AF and their impact on mortality from a large 14-year naturalistic follow-up study. Methods Anonymous data of adult patients aged ≥18 with all types of HF and AF admitted to several hospitals in the North of England between 2000 and 2013 was obtained and processed using the ACALM (Algorithm for Co-morbidity, Associations, Length of stay and Mortality) study protocol. ACALM uses the ICD-10 and OPCS-4 coding systems to identify patients and the methodology has been published widely. Analyses were performed comparing mortality between patients with HF, AF and combined HF and AF at baseline and their development during follow-up. Results At baseline, of 929,552 adult patients 29,164 (3.1%) had AF, 19,474 (2.1%) had HF, and 5,728 (0.6%) had both HF and AF. Of those with AF at baseline, 1,647 (5.6%) developed HF during follow-up, and of those with HF at baseline, 824 (4.2%) developed AF during follow-up. Demographics and crude mortality rates are shown; see Table. Patients with combined AF and HF at baseline had increased mortality than patients with AF or HF alone. Patients with AF at baseline that developed HF, and patients with HF at baseline that developed AF, experienced a greater mortality compared to those with combined HF and AF at baseline; see Figure. Conclusion Concomitant AF and HF is associated with substantial mortality and risk of death, irrespective of which disease develops first. In light of limited current treatment for these patients, future therapies to specifically target the combined HF and AF group are required.

Background Venous thromboembolism (VTE) is the most common preventable cause of death with safe and effective prevention measures available. Inpatients at high risk for VTE often fail to be provided prophylaxis despite clear guidelines and this mismatch between VTE prophylaxis and thromboembolic risk is a major issue for clinicians. We sought to clarify compliance of practice with the NICE quality standard and to assess accuracy of the Commissioning for Quality and Innovation (CQUIN) VTE form. Methods A point prevalence study was performed involving a comprehensive review of 100 consecutive patients at Barnet Hospital. We assessed compliance against the NICE guideline 92 by ensuring appropriate assessment of VTE and bleeding risk, clarifying that those where the VTE risk outweighs the bleeding risk are offered prophylaxis. We also assessed the accuracy of VTE risk assessment form completion using validated bleeding risk (HASBLED) and VTE risk (Wells) scores. We implemented technical improvements in the VTE risk assessment form; medical education through mandatory completion of VTE eLearning modules; and involvement of the MDT through grand round discussions. Following implementation, a reaudit of 50 patients was performed. Results In 100 patients assessed, mean age was 71 years, 55 were male, with mean weight 74.8kg; see Table 1. Based on the drug chart, VTE prophylaxis was appropriately offered in 69% of patients; see Figure 1. The VTE risk assessment form was accurately completed in 57% for VTE risk status, in 69% for bleeding risk, and in 69% for VTE prophylaxis prescribed. After implementations, the reaudit revealed VTE prophylaxis was appropriate in 88%, VTE risk assessment form was accurate in 78% for VTE risk status, 90% for bleeding risk, and 89% for VTE prophylaxis prescribed. The section of the drug chart devoted to VTE risk assessment was poorly utilised; 21% in the initial audit and 18% in the reaudit. Conclusion Whilst single centre and modest in size, this robust, complete audit demonstrated compliance with VTE prophylaxis guidelines was poor, for both risk assessment and appropriate prescribing. Technical improvements to the VTE form, educating trainees and involving the MDT significantly improved compliance with guidelines. Future work is required to overcome accuracy issues of form completion ensuring patients receive optimal care.

Background Digoxin use in heart failure and atrial fibrillation are common but declining, and remain the subject of conflicting clinical viewpoints. Recent observational studies have suggested increased mortality in patients receiving digoxin. We sought to clarify the impact of digoxin on clinical events, accounting for study designs, methodology and potential bias, regardless of clinical indication. Methods A comprehensive search of Medline, Embase and Cochrane from 1960 onwards identified 59 studies. 40 studies were suitable for meta-analysis with 67 study analyses comparing digoxin with either placebo or no treatment: 34 unadjusted, 19 adjusted, 10 propensity-matched and 4 randomised controlled trials (RCTs). All-cause mortality was meta-analysed using a random effects model according to study design and the review was prospectively registered (PROSPERO: CRD42014010783). Results 467,273 patients were included for meta-analysis. Those treated with digoxin were 2.4 years older than control (weighted difference; 95% CI 1.3–3.5) with lower ejection fraction (33% vs. 42%) and more diabetes. Concomitant use of diuretics and anti-arrhythmic drugs (AAD) was also greater with digoxin therapy (see Table 1). Compared to control, the pooled risk ratio for death in digoxin-treated patients was 1.7 in unadjusted observational analysis (95% CI 1.5–2.0), 1.9 in adjusted observational analyses (95% CI 1.5–2.3), 1.1 in propensity-matched analyses (95% CI 1.0–1.4) and 1.0 in RCTs (95% CI 0.9–1.1); see Figure 1. Meta-regression of observational studies confirmed that differences between treatment arms had a significant impact on the risk associated with digoxin use, including diabetes (p = 0.01), diuretics (p = 0.001), and AAD (p = 0.01); see Figure 2. Conclusion Digoxin is not associated with increased mortality in RCTs. The impact of digoxin on clinical outcomes should not be assessed in observational studies due to fundamental differences in patients receiving treatment. Future RCTs are crucial to accurately estimate the clinical value of digoxin therapy on clinical outcomes.