Specialized Atrial Fib Clinic Reduced Deaths, Hospitalizations



NEW ORLEANS – A specialized clinic that relies on a three-pronged–team approach for the treatment of atrial fibrillation achieved substantial reductions in cardiovascular hospitalizations and cardiovascular deaths, compared with usual care, in a randomized, open-label trial.

Specifically, cardiovascular death was reduced by nearly three-fourths with the specialized intervention. The three pillars of the program were nurse-led care, guideline-directed management of atrial fibrillation (AF), and support software based on clinical guidelines.

"Effective AF management can enhance appropriate treatment, coordinate the delivery of care more efficiently, and lead to improved outcomes, as we have shown in this trial. We can’t pinpoint the nurses or guidelines or software as the sole reason for our results. I think the secret is the integrated approach, combining these three ingredients," said principal investigator Dr. Robert G. Tieleman of Martini Hospital Groningen (the Netherlands), who presented the results jointly with Jeroen M.L. Hendriks, M.Sc., a nurse at Maastricht (the Netherlands) Hospital, at the annual meeting of the American College of Cardiology.

AF treatment guidelines are followed only about 60% of the time, according to the European Heart Survey of 5,000 patients in 35 countries. The survey findings led the Dutch researchers to design an AF treatment program based on established guidelines.

At visit 1, nurses gave patients extensive questionnaires to fill out, took medical histories, performed physical exams, and administered additional tests as needed. At visit 2, a supervising cardiologist and the nurse examined the patient’s profile (created from a computerized database of information obtained on that patient at visit 1), and the software provided a treatment plan for each patient based on AF guidelines and oral anticoagulation therapy to prevent clotting. Follow-up visits with the nurse focused on treatment according to guidelines, including medications, devices, smoking cessation, lifestyle, and education.

For the study, 712 patients with newly diagnosed AF were randomized to nurse-led care or usual care by a general cardiologist, and were followed for at least 1 year. The patients’ mean age was 66 years. About 55% of the nurse-led group and 62% of the usual care group were men. Overall, about 54% of patients had paroxysmal AF, about 15% had persistent AF, and about 22% had permanent AF. About 83% were symptomatic.

At a mean follow-up of 22 months, the primary composite end point of cardiovascular death or hospitalization occurred in 51 patients (14.3%) in the nurse-led group and in 74 patients (20.8%) in the usual care group, representing a significant relative risk reduction of 35% for those randomized to nurse-led care.

Cardiovascular death was reduced by 72% in the nurse-led care group: 4 patients (1.1%) vs. 14 patients (3.9%), respectively. Cardiovascular hospitalizations were reduced by 34% in the nurse-led care group: 48 patients (13.5%) vs. 68 patients (19.1%), respectively.

Guidelines for AF were followed much more often in the nurse-led group, as would be expected. Six different recommendations (two related to diagnostics and four to therapy) were followed. In the nurse-led group, these six guidelines were followed 80% of the time, compared with 40% of the time in the usual care group. Importantly, 99% of the nurse-led group adhered to the recommendation related to appropriate antithrombotic therapy, compared with 83% of the usual-care group.

Dr. Prakash Deedwania

The AF clinic has been incorporated into the official outpatient clinic at the university hospital. The Maastricht team is helping other hospitals in the Netherlands to set up similar AF clinics.

Dr. Byron Kwock Lee of the University of California, San Francisco, said "this study underscores the complexity of AF and how important it is to stay on top of all the angles."

Dr. Prakash C. Deedwania, professor of medicine at the University of California, San Francisco in Fresno, commented, "This is a relevant study that touches on the crux of the problem of managing AF in this current cost-control environment. I’m struck by the excellent outcomes achieved by this team approach."

Dr. Tieleman said that a cost analysis will be conducted, but that he is confident that the team (nurse-led) approach will be cost effective. "Hospital admissions are costly. Nurses are cheaper," he commented.

Dr. Tieleman, Mr. Hendriks, and Dr. Deedwania said that they had no relevant financial disclosures.

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