Atrial fibrillation (AF) is the most common arrhythmia in adults, affecting between three and five million Americans. Looking ahead, experts say the prevalence of AF may double by 2030, and the healthcare system must be ready to adapt to the needs of a much larger, increasingly heterogeneous population of AF patients. A group of electrophysiologists who collectively have decades of experience treating AF joined Editorial Advisor Matthew R. Reynolds, MD, SM, for a roundtable discussion of how they will manage to treat more and more AF patients even as the U.S. healthcare system turns its focus from volume to value.
CVB Moderator: Matthew R. Reynolds, MD, SM, Cardiac Electrophysiologist at Lahey Hospital & Medical Center (Burlington, Mass.) and Associate Professor of Medicine at Tufts University School of Medicine (Boston)
Martin C. Burke, DO, Professor of Medicine at the University of Chicago
Eric N. Prystowsky, MD, Director of the Cardiac Arrhythmia Service at St. Vincent Hospital (Indianapolis), Consulting Professor of Medicine at Duke University Medical Center (Raleigh-Durham, N.C.), and Editor-in-Chief of the Journal of Cardiovascular Electrophysiology
Andrea M. Russo, MD, Professor of Medicine at Cooper Medical School of Rowan University and Director of Cardiac Electrophysiology and Arrhythmia Services and of CCEP Fellowship at Cooper University Hospital (Camden, N.J.)
Edward J. Schloss, MD, Medical Director of Cardiac Electrophysiology at The Christ Hospital (Cincinnati)
Paul D. Varosy, MD, Director of Cardiac Electrophysiology at the Veterans Affairs Eastern Colorado Health Care System and Associate Professor of Medicine at the University of Colorado (Aurora)
“We have embraced this quest”
CVB (Reynolds): Fifteen years ago, when I was training, it was the beginning of the catheter ablation era for AF. Much of the growth in electrophysiology (EP) procedures had to do with implantable defibrillators and CRT. Today, in my practice, a larger and larger proportion of my time is tied up in managing AF patients and doing AF procedures. What has been the impact of AF on EP programs?
Prystowsky: Atrial fibrillation is the unconquered land. It was considered for many years this little orphan in the corner. Just give the patients warfarin and go home. But it’s taken on a real life of its own. Most EP labs are now fueled by AF ablation, to the point, unfortunately, that modern-day EP trainees may not be learning enough about ablation of AV node reentry and WPW [Wolff-Parkinson-White] reentry.
Electrophysiologists are key to the appropriate care of AF patients, and many of us have broadened our programs. There’s been an avalanche of new research in the area. In the end, it will benefit the populations, certainly in Western society, that we have embraced this quest.
Russo: Atrial fibrillation has become an epidemic in our emergency rooms, and our offices are filled with patients needing to be seen for AF. The amount of monitoring, follow-up and education has increased. Shared decision making has increased the time we spend educating patients and their families. Trying to keep people out of the hospital is a big key here, not in the emergency room for every episode of AF. We’ve put a heavier emphasis on outpatient care, when it’s needed, to follow response to therapies. We’re working on a better system and algorithm to manage and increase cost-effectiveness.
There’s a movement to transition EP training from a one-year requirement to two years of dedicated clinical time, partially reflecting the complexity of mastering procedures. Meanwhile, in the Northeast at least, there are many programs where we train fellows who have a hard time getting jobs locally. Do we have enough electrophysiologists, or should we be training more? Does this affect how we’re deploying allied professionals?
Prystowsky: The two-year EP training requirement will apply 100 percent of the time starting in 2017. There is a group of elecrophysiologists who will be phasing themselves out of the EP lab because my generation and the one right behind me are not as involved in performing very complex ablation
procedures. Having said that, fewer people are applying to EP fellowship programs. It’s a bit perplexing. I think it’s because everybody would like to practice in Boston, San Diego or San Francisco; there is a maldistribution. We clearly need more sophisticated electrophysiologists, but the application pool has decreased.
Burke: A major advance