John Mandrola


August 31, 2014

Atrial fibrillation is a complex disease. Presenting at the European Society of Cardiology 2014 Congress in Barcelona, Dr Isabelle Van Gelder (University of Groningen, Netherlands) said AF is both an electrical disease and a consequence of preceding associated diseases. In a session titled "Closing the mortality gap in atrial fibrillation," she reminded us that treating AF involves more than just looking at the heart rhythm. Van Gelder was a coauthor of a recent white paper in the Journal of the American College of Cardiology that urged us to stop using the old term lone atrial fibrillation.[1] The reason: AF seldom occurs in isolation—there are often associated diseases, which affect the structure and electrical properties of atria cells. So, yes, it's as I have said before: in the human body, it's all connected.

In the same session, Dr John Camm (St George's University, London, UK) began his presentation on the role of dedicated AF clinics by pointing out the complexity of treating people with AF. That is an easy case to make. It's a much harder case, however, to show that a nurse-led multidisciplinary approach improves outcomes. But if anyone can make the case, the eminent and elegant Dr Camm can.

He began by showing registry data of AF treatment in the real world. It's not good news. Undertreatment, especially with anticoagulant drugs, is common. And overtreatment is prevalent as well. Camm then showed a sliver of the vast amounts of data that confirm the notion that adherence to guideline-directed care improves outcomes. Who can argue with good INR control, appropriate use of anticoagulants and rate-control drugs, and attention to associated diseases?

Herein lies the problem. It's hard for one physician, even a cardiologist, to accomplish all these things. One of the first lessons you learn in medical training: good medicine is a team sport. And for a disease like AF, where danger lurks from both the disease and its treatment, teamwork makes intuitive sense.

Ah, but I bring you more than intuition.

Prof Jeroen Hendriks

I have Prof Jeroen Hendriks (Maastricht University, Netherlands), whose work won an investigators' award at this year's ESC sessions. Prompted by Dr Camm's talk, in which he cited the work from Maastricht, I attended Dr Hendriks's session later in the day and then sat down with him afterward to talk about this award-winning Dutch approach to patients with AF.

Doctors, you might want to sit down before reading further.

Dr Hendriks's group has shown that a nurse-led, computer-aided, integrated program improves adherence to guidelines, lowers hospital admissions, and improves cardiovascular mortality. In a clinical trial published previously in the European Heart Journal, this group compared nurse-led care with standard physician care.[2]

Here is how it works at Maastricht University. A nurse interviews the patient and sees to it that the standard tests—ECG, 24-hour Holter, echocardiography, thyroid function—are performed. Intake data from a questionnaire are entered into a software program, which is designed to be an electronic checklist of sorts. The focus of the evaluation is on the whole person, not just the rhythm. Patients with an elevated CHA2DS2-VASc score, for instance, get more than just the talk about anticoagulation. These patients, by virtue of their score, have associated diseases that require attention. Three other important facets of the strategy: Nurses do more than just educate patients—they coordinate care, maintain a relationship with the supervising cardiologist, and encourage patients to participate actively in their care.

The results of their 712-patient trial were impressive. The primary end point was a composite of cardiovascular hospitalization and cardiovascular death:

  • Significantly fewer patients in the AF-clinic group reached the primary end point: 51 (14.3%) vs 74 (20.8%) in the usual-care group.

  • Cardiovascular deaths were lower in the AF-clinic group: 1.1% vs 3.9%.

  • Cardiovascular hospitalizations were lower in the AF-clinic group: 13.5% vs 19.1%.

In addition to these hard end points, nurse-led care led to striking adherence with guidelines. Compared with standard physician care, patients in the nurse-led care were much more likely to be on standard treatments and not on inappropriate treatments. For instance, 99% of the nurse-led cohorts were taking anticoagulation drugs vs only 83% in the standard group. What's more, nonuse of rhythm-control strategies in asymptomatic patients was more frequent in the nurse-led cohort (95% vs 85%).

Dr Hendriks' presentation here at ESC focused on patient knowledge and cost-effectiveness of the nurse-led integrated strategy.[3] Their analysis showed improvement in both—not surprisingly. Preventing hospital admissions and strokes goes a long way to saving money.

If the goal in treating people with AF is good outcomes and cost-effectiveness, Dr Hendriks has it right: "There has to be an active and effective connection between patient, nurse, and doctor."

To address the critics who say this was just a single-center study with small numbers of patients, Dr Hendriks and colleagues will confirm their findings in a larger trial. The Integrated Care for Atrial Fibrillation (RACE-4) trial will enroll patients from eight centers in the Netherlands and compare a nurse-led integrated AF clinic approach with standard physician-led care. RACE-4 is enrolling now and plans to study more than 1700 patients, with results available in 2016.

This leads me back to Dr Camm, who reminded us that the most recent National Institute for Health and Care Excellence (NICE) guidelines have noticed this work. In the UK, experts recommend a personalized package of care for patients with AF, which is essentially identical to the Maastricht approach.

In the Q&A session, Dr Camm was asked why nurses perform better than doctors. He first paused and chuckled and then answered: "Most docs are busy, and most of us can easily overlook critical issues, whereas if we have a person whose job it is to check these things, it is less likely to be missed."

But I would go further than just substitution of workload. To me, the advantage of an integrated clinic is its focus on providing knowledge and patient empowerment. For if you do that, you do a lot for the patient with AF.

There are thousands of abstracts at this meeting—new drugs, new devices, new surgeries, and new approaches to human disease. Ultimately, though, caring for people falls to humans working together with a shared vision. The best sports teams are never a group of all-stars but rather a team where everyone plays their role.

If only the Maastricht approach to patient care were the norm. Surely, this would be a new solution to an old problem.



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