ACC: Specialized AF clinic can enhance guideline adherence, patient outcomes
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NEW ORLEANS—The management of atrial fibrillation (AF) patients in a specialized AF-clinic improves outcomes compared with usual care, but it is difficult to pinpoint nurses, guidelines or dedicated software as the sole reason for the results, so an integrated effort is recommended based on a clinical trial presented April 5 at the 60th American College of Cardiology’s (ACC) scientific sessions.

Guidelines for managing AF help reduce such risks, but a Euro Heart Survey, covering more than 5,000 patients in 35 countries, found that cardiologists often fail to follow the guidelines, and non-adherence to guidelines increased morbidity and mortality, according to the researchers.

In response to these findings, the study’s lead author Jeroen M. Hendriks, MSc, a cardiac nurse at Maastricht University Medical Centre in Maastricht, the Netherlands, and colleagues designed an AF program built around established treatment guidelines. He explained that the AF clinic is an integrated chronic care program with four components: substitution of care by specialized nurses, management of AF according to guidelines, dedicated knowledge software that acts like an electronic patient chart, and supervision by cardiologists.

The study analyzed outcomes for 712 patients newly diagnosed with AF who were referred to a specialized AF clinic or to usual care by a cardiologist in the outpatient clinic.

At the clinic, detailed medical information about patients is fed into a database, where it is used to create individual risk profiles. The software then provides a treatment plan based on AF guidelines and oral anticoagulation therapy to prevent blood clots. As part of this process, the nurses focus on patient education on AF, treatment and general healthier lifestyle information, and clinic staff coordinate care with the referring general practitioner.

At the start of the study, cardiovascular conditions represented among patients in the AF clinic’s nurse-led care (NLC) group and usual care (UC) group included hypertension (187 NLC vs. 193 UC), stroke (44 NLC vs. 45 UC), coronary artery disease (33 NLC vs. 38 UC) and heart failure (25 NLC vs. 25 UC).

The primary endpoint was a composite of death from cardiovascular causes and cardiovascular hospitalization for heart failure; ischemic stroke; MI; systemic embolism; major bleeding; defined arrhythmic events; and life-threatening adverse effects of drugs.

After a mean follow-up of 22 months, 125 patients had reached the primary endpoint: 14.3 percent in the AF clinic group and 20.8 percent in the UC group. Deaths and hospitalizations were significantly lower among patients treated at the AF clinic: deaths, 1.1 percent vs. 3.9 percent, and hospitalizations, 13.5 percent versus 19.1 percent.

Also, taking six guideline recommendations (including echocardiogram, lab assessment of Thyroid Stimulating Hormone, application of appropriate anti-thrombotic treatment and appropriate prescriptions of class I or class III drugs), patients were better followed in the NLC group (81 vs. 40 percent).

“Effective AF management can enhance appropriate treatment, coordinate the delivery of care more efficiently and bring improved outcomes, as we showed in this trial,” said principal investigator Robert G. Tieleman, MD, PhD, a cardiologist at Martini Hospital in Groningen, the Netherlands. “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 – the combination of these three ingredients.”

As a study discussant, Prakash C. Deedwania, MD, chief of cardiology at the University of California, San Francisco, said the “excellent study shows remarkable results, especially in the era of cost-containment."

Tielelman noted that the “compliance was so good because nurses spend more time with the patients, and are less expensive than doctors.” For the cost-effectiveness considerations, the researchers are looking into the data now.

The AF clinic now is officially part of the outpatient clinic at University Medical Centre. Also, Hendricks reported that “many other hospitals” in the Netherlands are setting up AF clinics with help from the Maastricht team, and the Dutch Society of Cardiovascular Nursing is starting a working group for nurses on how to develop and evaluate an AF clinic.