Arrhythmia

Experts divided over need for dedicated AF clinics


People with atrial fibrillation who are treated in dedicated clinics achieve better outcomes than patients who don’t but experts are divided about whether there is enough evidence to support costly integrated care models in Australia.

Australian authors of a meta analysis published in The BMJ journal Heart found that dedicated atrial fibrillation (AF) programs improved adherence to guidelines, lowered hospital admissions, and improved cardiovascular mortality.

But the analysis has highlighted that little evidence exists about integrated care for AF, with only two randomised controlled trials and one non-randomised trial meeting the inclusion criteria – and it has experts divided about whether it’s too early to start pushing for such programs in Australia.

Writing in a linked editorial cardiologist Professor Simon Stewart from the Mary McKillop Institute for Health Research in Melbourne pointed out that while the analysis showed integrated management was associated with a significant reduction in the risk of all-cause mortality and cardiovascular hospitalisation it did not affect AF-related hospitalisation and cerebrovascular events.

“At this stage there is little sign that integrated management has ‘disease-specific’ effects on AF. Indeed, based on available evidence, one might argue that these data merely support the extension of current disease management programs (particularly HF programmes) to include all patients affected by AF,” he wrote.

He also stressed that more adequately powered RCT’s would be needed to make sure that ‘real world’ patients would truly stand to gain survival benefits from what would be costly programs.

But speaking to the limbic Dr Jeroen Hendriks from the University of Adelaide’s Centre for Heart Rhythm Disorders and lead author on the analysis maintained that AF needed to be singled out and treated as a chronic condition in its own right.

“For a long time we have had HF clinics and focused on that disease but AF has never received that same attention. I don’t agree that we should include all AF patients in the HF models – it might work for those older patients who have heart failure and AF– but there are a lot of younger patients, and patients where we really have to work on primary prevention – it’s these patients that need a specialised approach.”

Dr Hendrik’s previous work in integrated AF care at Maastricht University in the Netherlands won him a European Society of Cardiology investigators’ award in 2014.

He said an integrated model of care to AF is now recommended in European guidelines released in August last year.

Penned by clinical cardiologists, electrophysiologists, cardiac surgeons, a neurologist and a cardiovascular nurse they were the first to target every atrial fibrillation specialist.

The guidelines recommend creating AF Heart Teams with experience in anti-arrhythmic drugs, catheter ablation and surgery.

“In the Netherlands it took 10 years before the relevant societies and colleges were really convinced about integrated care but now its in the guidelines – that’s really the icing on the cake,” Dr Hendriks said.

In the Netherlands model nurses also did more than just educate patients—they coordinated care, maintained a relationship with the supervising cardiologist, and encouraged patients to participate actively in their care.

This led to fewer cardiovascular deaths in the AF-clinic group (1.1% vs 3.9%) and cardiovascular hospitalisations were also lower (13.5% vs 19.1%), Dr Hendriks said.

While he agrees that more evidence is need to establish the best way to deliver an integrated AF care program, Dr Hendriks said the gaps in evidence shouldn’t stop progress in initiating integrated care practices now.

 

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