Specialized Atrial Fibrillation Clinic reduces cardiovascular morbidity and mortality in patients with atrial fibrillation

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Specialized Atrial Fibrillation Clinic reduces
cardiovascular morbidity and mortality in
patients with atrial fibrillation
Jeroen ML Hendriks, MSc Robert G Tieleman, PhD,
MD Department of Cardiology Cardiovascular
Research Institute Maastricht University Medical
Centre, The Netherlands Martini Hospital
Groningen, The Netherlands
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Euro Heart Survey Antithrombotics
according to CHADS2 score

• Poor adherence to guidelines on management of AF
• Non-adherence to guidelines increased morbidity /
  mortality
• Nieuwlaat et al. EHJ 2005, 2006

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Multivariate analysis
antithrombotic guideline deviance
Nieuwlaat et al. Am Heart J 2007
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The AF-Clinic An integrated chronic care program
for patients with atrial fibrillation

• Substitution of care by specialized nurses
• Management of AF according to guidelines
• Dedicated knowledge software
• Supervision by cardiologists

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Hypothesis
Nurse-led, guideline based, software-supported
AF-Clinic, supervised by cardiologists improves
clinical outcome in patients with atrial
fibrillation in comparison to usual care
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Methods

• PROBE Prospective, Randomized, Open label,
  Blinded Endpoint trial, comparing the AF-Clinic
  to usual care
• Randomization of 712 pts with newly diagnosed AF
  into Nurse-led Care group or Usual Care group
• Inclusion criteria
• Age 18 years
• AF documented on ECG
• Exclusion criteria
• Unsatisfactorily treated co-morbidity
  (hypertension, heart failure, )
• Follow-up at least 1 year

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Primary endpoint (composite)

• Cardiovascular mortality
• Cardiovascular hospitalization for
• Heart failure
• Stroke
• Acute myocardial infarction
• Systemic embolism
• Bleeding
• Arrhythmic events
• Atrial Fibrillation
• Syncope
• Sustained ventricular tachycardia
• Cardiac arrest
• Life-threatening effects of drugs

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Baseline characteristics
Characteristics Nurse-led Care (N 356) Usual Care (N 356)
Age - yr 66 13 67 12
Male sex - no () 197 (55.3) 221 (62.1)
Type of AF - no ()
Paroxysmal 190 (53.4) 203 (57.0)
Persistent 68 (19.1) 44 (12.4)
Permanent 75 (21.1) 84 (23.6)
Symptomatic AF - no () 294 (82.6) 296 (83.1)
History of underlying disease
Hypertension 187 (52.5) 193 (54.2)
Diabetes mellitus 50 (14.0) 46 (12.9)
Previous stroke / TIA 44 (12.4) 45 (12.6)
Coronary artery disease 33 (9.3) 38 (10.7)
Myocardial infarction 19 (5.3) 22 (6.2)
Congestive heart failure 25 (7.0) 25 (7.0)
Peripheral vascular disease 13 (3.7) 20 (5.6)
Hyperthyroidism 12 (3.4) 12 (3.4)
Mitral or aortic valve disease 12 (3.4) 21 (5.9)
No underlying heart disease 6 (1.7) 7 (2.0)
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Baseline characteristics
Characteristics Nurse-led Care (N 356) Usual Care (N 356)
CHADS2 score - no ()
0 107 (30.0) 95 (26.7)
1 122 (34.3) 135 (37.9)
gt1 127 (35.7) 126 (35.4)

Threatment - no ()
Beta-blocker 164 (46.1) 187 (52.5)
Digitalis 59 (16.6) 43 (12.1)
Verapamil 44 (12.4) 18 (5.1)
Vaughan-Williams class I III 105 (29.1) 88 (24.7)
Vitamin K antagonist 218 (61.2) 188 (52.8)
Aspirin 118 (33.1) 108 (30.3)

Echocardiographic findings
Size of left atrium, long axis - mm 42 6 43 8
LV end-diastolic size - mm 49 6 49 6
LV end-systolic size - mm 34 6 34 6
LV ejection fraction - 57 10 56 12
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Results

• After a mean follow-up of 22 months
• Composite end point
• - 51 patients (14.3) Nurse-led Care
• - 74 patients (20.8) Usual Care
• (HR 0.65, 95 CI 0.45-0.93)

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Results composite endpoint
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Results

• Cardiovascular hospitalization
• - 48 patients (13.5) Nurse-led Care
• - 68 patients (19.1) Usual Care
• (HR 0.66, 95 CI 0.46-0.96)

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Causes of cardiovascular hospitalization
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Results

• Cardiovascular death
• - 4 patients (1.1) Nurse-led Care
• - 14 patients (3.9) Usual Care
• (HR 0.28, 95 CI 0.09-0.85)

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Causes of cardiovascular death
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Results guideline adherence

• Echocardiogram performed
• Laboratory assessment of Thyroid Stimulating
  Hormone
• Application of appropriate anti-thrombotic
  treatment
• Appropriate prescription of Vaughan-Williams
  class I or III
• Avoiding rhythm control strategy in asymptomatic
  patients
• Avoiding rhythm control drugs in patients with
  permanent AF

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Results guideline adherence

• Echocardiogram performed
• Laboratory assessment of Thyroid Stimulating
  Hormone
• Application of appropriate anti-thrombotic
  treatment
• Appropriate prescription of Vaughan-Williams
  class I or III
• Avoiding rhythm control strategy in asymptomatic
  patients
• Avoiding rhythm control drugs in patients with
  permanent AF

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Conclusion
Management of atrial fibrillation patients in a
specialized AF-Clinic improves outcome compared
to usual care.
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Members of the study group

• Steering Committee
• HJGM Crijns
• RG Tieleman
• R de Wit
• HJM Vrijhoef
• Adjudication Committee
• C Franke
• H ten Cate
• GVA van Ommen
• RJMW Rennenberg

• Writing Committee
• HJGM Crijns
• JML Hendriks
• RG Tieleman
• HJM Vrijhoef
• R de Wit
• MH Prins
• R Pisters
• LAFG Pison
• Y Blaauw

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Back-up slides
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Discussion
Difficult to pinpoint nurses or guidelines or
dedicated software as the sole reason for
results Improved guideline adherence and
outcomes due to an integrated approach a
combination of ingredients
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Results multivariate analyses