AF Burden, Resource Use Declines With Dedicated Risk-Factor-Management Clinic

Fran Lowry

April 06, 2017

ADELAIDE, AUSTRALIA — Integrating a physician-led weight- and risk-factor-management (RFM) program into the overall management of patients with atrial fibrillation (AF) improves their symptoms of AF and ability to maintain sinus rhythm, according to new research[1].

In addition, "We found that such a strategy is highly cost-effective," senior author Dr Prashnathan Sanders (University of Adelaide, Australia) told heartwire from Medscape in an email. "A dedicated clinic focused on patient engagement and setting achievable goals is crucial for this process."

As a prelude to their study, published March 29, 2017 in JACC: Clinical Electrophysiology, Sanders and his group had noticed that many of their patients waiting for AF ablation procedures were highly symptomatic.

"While they were waiting, we got them started on managing their risk factors. To our surprise, we saw anecdotally that the AF improved significantly in some," he said.

The anecdotal finding was confirmed in a pilot randomized controlled trial that showed a marked reduction in AF symptoms and reduced AF burden with risk-factor management. The LEGACY study followed, in which the researchers analyzed their long-term registry data and found that progressive weight loss had a dose-dependent effect on long-term freedom from AF.

"However, it was not clear if a dedicated risk-factor-management clinic is cost-effective, and this is what we sought to evaluate in the CENT study," Sanders said.

"The weight- and risk-factor-management program is simply one physician with one patient. It involves getting to know the patient. We get them to keep a food, activity, and blood-pressure diary and use this to then set with the patient achievable targets for each risk factor," he explained.

"We review these as required, in general every 3 months, but where we are not achieving our targets we sometimes need to do this more frequently—at times weekly."

The CENT population included 208 patients who were offered and accepted the risk-factor-management program, and 147 patients who declined the program served as controls. Management of AF was done in a separate arrhythmia clinic by physicians who were blinded to the patients' study group.

All patients had a BMI ≥27 kg/m2 and one or more CV risk factors (hypertension, glucose intolerance, dyslipidemia, sleep apnea, and alcohol or tobacco use).

The intervention group received counseling to achieve behavioral change for weight management and increasing physical activity and were managed for their other risk factors individually according to AHA/ACC guidelines.

The control group was given information on management of risk factors and encouraged to begin risk-factor management under the direction of their treating physician.

Risk Factor Results in the Risk-Factor-Management (RFM) Group vs Controls

                                                                                                                                                                                                                                                                                                                                                                                                       
Risk factor RFM (n=208) Controls (n=147) P
Systolic blood pressure (mm Hg) −10.1−3.3<0.001
Weight (kg) −10.1−3.3<0.0001
Well-controlled LDL-C and non-HDL-C (% of patients) 47150.02
HbA1c <7% (% of patients) 71520.003
Severe obstructive sleep apnea (% of patients) 31390.003

The mean follow-up in the intervention group was 47 months (range 29–65) and in the control group 49 months (range 31–67).

Patients in the intervention group achieved greater improvement in various cardiac risk factors and steeper reductions in AF burden compared with their control counterparts.

Measures of AF Burden in RFM Group vs Controls

                                                                                                                                                                                                       
AF burden RFM, n=208 (%) Controls, n=147 (%) P
Ablation- and drug-free 35180.001
Arrhythmia-free survival 79440.001

Patients in the RFM group used fewer healthcare services than controls; they had fewer unplanned specialist visits (P=0.001), emergency presentations (P=0.001), and hospitalizations (P=0.03); and underwent fewer cardioversions (P=0.002) and ablation procedures (P=0.03).

In addition, the risk-factor-management program likely saved money. The mean expected healthcare cost per patient over the 4-year study was $17,421 in the RFM group compared with $20,388 in the control group.

"The CENT study was motivated by the fact that we need policy change and funding to be able to make such clinics available to all with AF. We would like to see this change to curtail the epidemic of AF. The cost is really in the clinical visits and the physicians' time. As shown in the study, in terms of procedures avoided, reduced emergency-department presentations, and so on, it becomes very cost-effective."

The study was funded by the Centre for Heart Rhythm Disorders at the University of Adelaide, Australia. Sanders reports financial relationships with the National Health and Medical Research Council of Australia, the National Heart Foundation of Australia, Biosense-Webster, Medtronic, CathRx, St Jude Medical, Boston Scientific, Biotronik, and Sorin. Disclosures for the coauthors are listed in the paper.

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