‘Think Big, But Act Small’: Specialized A-fib Clinic Cuts Mortality

BOSTON, MA—Patients with A-fib fare much better when they receive care within a multidisciplinary, nurse-led clinic instead of usual outpatient care from a cardiologist, new randomized data show.

Through about 3 years of follow-up, 3.7% of patients treated in the specialized clinic died from any cause, compared with 8.1% of those who received usual care (HR 0.44; 95% CI 0.23-0.85), Jeroen Hendriks, RN, PhD (Royal Adelaide Hospital, Australia), reported at the Heart Rhythm Society (HRS) 2018 Scientific Sessions here last week.

That accompanies the previously reported reduction in the primary composite endpoint of cardiovascular hospitalization or mortality (14.3% vs 20.8%; HR 0.65; 95% CI 0.45-0.93).

Hendriks said that a multidisciplinary approach for A-fib is necessary because successful management involves dealing with rhythm and rate control, prevention of thromboembolic strokes, risk factor control, and assessment of the needs of each individual patient in terms of self-management.

“[For] a single healthcare professional to really address these areas adequately, I think it’s almost impossible,” he told TCTMD. It takes a core team consisting of the patient with a cardiologist, nurse, and pharmacist working in collaboration with other specialists “to really bring this comprehensive integrated approach to life,” Hendriks said.

 [For] a single healthcare professional to really address these areas adequately, I think it’s almost impossible. Jeroen Hendriks 

This concept is particularly important to highlight at a meeting like HRS, which has loads of presentations about specific devices and procedures, he added.

“I really believe that you can do a procedure that is as complex as you can imagine, but if you don’t explain to the patient what we’re expecting from them—for example, just take their anticoagulation every day at the right time and take the right medication—then the intervention will fail, because the patient will get complications and then we’re even further away from where we started,” Hendriks said.

Bringing It All Together

The most recent A-fib guidelines from Europe focus on the importance of integrated, team-based care for all patients with A-fib, who would be expected to take a more active role in their own treatment.

That was preaching to the choir at Maastricht University Medical Center in the Netherlands, where researchers that included Hendriks—who subsequently left for Australia—had already implemented such a program. That specialized clinic incorporated three important components, Hendriks said:

• Close collaboration between a nurse and a cardiologist in a multidisciplinary team
• A focus on guideline adherence
• A dedicated software system that steers patients and healthcare professionals through the care process and helps support clinical decision-making and boost adherence to guideline recommendations

The investigators evaluated the impact of the specialized clinic, in which patients had regular visits with nurses, in a trial that randomized 712 patients with newly detected A-fib to nurse-led integrated care or usual care overseen by a cardiologist.

The differences in clinical outcomes seen between the two groups—which included a nonsignificant trend toward less cardiovascular mortality (2.5% vs 4.2%; HR 0.59; 95% CI 0.26-1.34) and a significant reduction in cardiovascular mortality (1.1% vs 3.9%; HR 0.28; 95% CI 0.09-0.85) in the clinic group—could be attributed to a few things, Hendriks said.

For one, patients who had regular contact with nurses may have been better educated about A-fib and better prepared to help manage the condition themselves. Improved guideline adherence likely also played a role, he said, pointing to the greater use of appropriate oral anticoagulation based on stroke risk as an example. And finally, the decision-support software provided guidance to the care team, including alerts when something deviated from the plan.

Hendriks touted the integrated approach, however, and said putting all of the pieces together is key. “I can’t say what component is contributing to this, but I think what is very much important is to sit down with your patient, take time, listen, and see what is important for them, what are their preferences, look at what we have on evidence-based guidelines, for example. Bring that together and make it happen.”

‘We Need To Organize Care’

Commenting for TCTMD, Ratika Parkash, MD (Dalhousie University, Halifax, Canada), singled out the increased interactions with nurses as a main driver of the benefits seen in the trial, with the use of the decision-support software to enhance the use of guideline-directed therapy also serving a crucial role.

When patients spend more time with nurses, “that allows for more questions by the patient to be answered, more information to be exchanged that the physician may not necessarily have the time to provide,” Parkash said. “So I think that’s the backbone of why this particular intervention is able to achieve what it’s able to achieve.”

She said she believes most of the benefits of the intervention likely come through decreasing heart failure progression, which is a major cause of mortality in patients with A-fib. “We talk a lot about stroke and stroke prevention, and it’s obviously very important, but the more important intervention that we can do for patients with atrial fibrillation is to prevent heart failure progression or incident heart failure,” Parkash said.

When asked about how easy it is to set up a specialized A-fib clinic, Parkash—whose team demonstrated the benefits of the approach at their center—said it is relatively straightforward as long as the resources are there to support it. It might be more difficult for smaller community hospitals to get a program up and running, but it’s possible that telemedicine technologies could overcome some of the barriers, she added.

However it’s done, “we need to organize care for our patients with atrial fibrillation because it can have a major impact on important outcomes like mortality, and it’s really one of the first interventions where we have been able to affect mortality for patients with atrial fibrillation,” Parkash said. “Many of the other interventions that we’ve looked at, including rhythm control and catheter ablation, have not been able to show this type of impact. So this really is a model that we should be trying to emulate and [trying to] sort out how we can do it within our resource-constrained environment.”

Hendriks said it can be challenging to convince hospital administrators that an integrated A-fib clinic is necessary, a problem the team in the Netherlands was able to overcome. Now, Hendriks is working on implementing a similar program at Royal Adelaide Hospital, and he advised others thinking about doing the same to use a measured approach to make it happen.

“I use the slogan, ‘Think big, but act small.’ So do it step by step and try to get further every time,” he said, noting that the Dutch clinic started with just a cardiologist, a nurse, and a laptop.

Still, though he believes in the power of integrated A-fib care, Hendriks said more evidence is needed to support the strategy. And that seems to be forthcoming. His team is planning a roughly 700-patient trial at four centers in Australia and two in New Zealand and there is a confirmatory trial currently being performed at eight centers in the Netherlands called RACE-4, which has enrolled 1,375 patients and is expected to be completed in November.