A proposal for interdisciplinary, nurse-coordinated atrial fibrillation expert programmes as a way to structure daily practice

A qualitative study of the experiences of interdisciplinary nurses during the COVID-19 outbreak following the announcement of the "Ten new guidelines" in China

BACKGROUND

On December 7, 2022, the Joint Prevention and Control Mechanism of China's State Council released the "Ten New Guidelines" to optimize the coronavirus disease 2019 (COVID-19) prevention policies further. This signaled a broader shift from "dynamic clearing" to "coexisting with the virus" nationwide.

OBJECTIVE

This study aims to examine the experiences and perspectives of interdisciplinary nurses during the COVID-19 outbreak in China after the implementation of the "Ten New Guidelines". The goal is to understand the challenges faced by this unique nursing group and inform organizational support to bolster their well-being and resilience.

METHODS

Two tertiary hospitals in southeastern Zhejiang Province were selected, with interdisciplinary nurses chosen as subjects. A constructivist qualitative research approach was employed, using semi-structured face-to-face interviews. Research data were collected through interviews and analyzed using content analysis.

RESULTS

Fifteen interdisciplinary nurses were included in this study. The analysis revealed four main themes and nine sub-themes. The main themes were: (1) ineffective organizational support (inadequate organizational care, poor PPE, excessive workload), (2) physiological distress after contracting COVID-19 (extreme physical fatigue, leakage of urine due to severe coughing), (3) fear of being wrong (fear of being reprimanded in public, psychological anxiety), and (4) family responsibility anxiety (difficulty of loyalty and filial piety, obligations to their children).

CONCLUSION

We provide new evidence that organizations must proactively address the support, training, and communication needs of staff, particularly interdisciplinary nurses, to supplement epidemic containment. This is also essential in helping mitigate the work-family conflicts such roles can create.

Nurse-led care after ablation of atrial fibrillation: a randomized controlled trial

AIMS

The added value of advanced practitioner nurse (APN) care after ablation of atrial fibrillation (AF) is unknown. The present study investigates the impact of APN-led care on AF recurrence, patient knowledge, lifestyle, and patient satisfaction.

METHODS AND RESULTS

Sixty-five patients undergoing AF ablation were prospectively randomized to usual care (N = 33) or intervention (N = 32) group. In addition to usual care, the intervention consisted of an educational session, three consultations spread over 6 months and telephone accessibility coordinated by the APN. Primary outcome was the AF recurrence rate at 6-month follow-up. Secondary outcomes were lifestyle factors (alcohol intake, exercise, BMI, smoking), patient satisfaction and AF knowledge measured at 1 and 6 months between groups and within each group. Study demographics at 1 month were similar, except AF knowledge was higher in the intervention group (8.6 vs. 7, P = 0.001). At 6 months, AF recurrence was significantly lower in the intervention group (13.5 vs. 39.4%, P = 0.014). Between groups, patient satisfaction and AF knowledge were significantly higher in the intervention group, respectively, 9.4 vs. 8.7 (P < 0.001) and 8.6 vs. 7.0 out of 10 (P < 0.001). Within the intervention group, alcohol intake decreased from 3.9 to 2.6 units per week (P = 0.031) and physical activity increased from 224.4 ± 210.7 to 283.8 ± 169.3 (P = 0.048). No changes occurred within the usual care group. Assignment to the intervention group was the only protective factor for AF recurrence [Exp(B) 0.299, P = 0.04] in multivariable-adjusted analysis.

CONCLUSION

Adding APN-led care after ablation of AF improves short-term clinical outcome, patient satisfaction and physical activity and decreases alcohol intake.

Telemedicine practices in adult patients with atrial fibrillation

BACKGROUND

Atrial fibrillation is a cardiac rhythm disorder associated with embolic stroke risk, decreased functional capacity, and worsening quality of life. Increasing patient access to atrial fibrillation specialists via telemedicine has the potential to improve patient outcomes.

OBJECTIVES

The purpose of this systematic review was to describe atrial fibrillation telehealth education treatment programs unrelated to postablation or early detection of atrial fibrillation.

DATA SOURCES

PubMed and CINAHL databases were searched using key terms identified by the authors and informed by a panel of clinicians with expertise in cardiac electrophysiology.

CONCLUSIONS

Little literature exists on educational telehealth programs for atrial fibrillation treatment unrelated to postablation or early detection of atrial fibrillation. Only three studies met our inclusion criteria. Three themes emerged from review of these studies: (a) atrial fibrillation requires specialty care that is difficult to obtain; (b) comprehensive atrial fibrillation education should include a broad overview of the condition, management options, stroke prevention, and symptom management; and (c) telemedicine is effective for diagnosing and managing atrial fibrillation.

IMPLICATIONS FOR PRACTICE

Telemedicine clinics for atrial fibrillation represent an emerging form of clinically important health care delivery. These clinics can potentially decrease wait time for specialty care access, reduce unnecessary emergency department visits, reduce stroke risk, and increase guideline adherence. Nurse practitioners are well suited to create and lead telemedicine atrial fibrillation clinics with relevant clinical expertise and collaborative skills.

A Nurse-Led Integrated Chronic Care E-Enhanced Atrial Fibrillation (NICE-AF) Clinic in the Community: A Preliminary Evaluation

The current physician-centric model of care is not sustainable for the rising tide of atrial fibrillation. The integrated model of care has been recommended for managing atrial fibrillation. This study aims to provide a preliminary evaluation of the effectiveness of a Nurse-led Integrated Chronic care E-enhanced Atrial Fibrillation (NICE-AF) clinic in the community. The NICE-AF clinic was led by an advanced practice nurse (APN) who collaborated with a family physician. The clinic embodied integrated care and shifted from hospital-based, physician-centric care. Regular patient education, supplemented by a specially curated webpage, fast-tracked appointments for hospital-based specialised investigations, and teleconsultation with a hospital-based cardiologist were the highlights of the clinic. Forty-three participants were included in the six-month preliminary evaluation. No significant differences were observed in cardiovascular hospitalisations (p-value = 0.102) and stroke incidence (p-value = 1.00) after attending the NICE-AF clinic. However, significant improvements were noted for AF-specific QoL (p = 0.001), AF knowledge (p < 0.001), medication adherence (p = 0.008), patient satisfaction (p = 0.020), and depression (p = 0004). The preliminary evaluation of the NICE-AF clinic demonstrated the clinical utility of this new model of integrated care in providing safe and effective community-based AF care. Although a full evaluation is pending, the preliminary results highlighted its promising potential to be expanded into a permanent, larger-scale service.

The effect of the clinical supervision model on nurses' performance in atrial fibrillation care

Background:

A model of clinical education for reducing the theory-practice gap is the clinical supervision model. The purpose of this study was to evaluate the effect of the clinical supervision model on nurses’ performance in Atrial Fibrillation (AF) care in a Critical Care Unit (CCU).

Materials and Methods:

This quasi-experimental study was conducted with a pretest-posttest design. Through stratified random sampling, 36 eligible nurses working in the CCU in Hospitals in Isfahan, Iran, were selected. The data gathering tools included a demographic questionnaire (7 items) and a performance checklist (44 items). Data were analyzed using descriptive (mean and standard deviation) and analytical statistics (ANOVA, LSD, post hoc test, and paired t-test). The level of statistical significance was p ≤ 0.05.

Results:

Paired t-test showed that there was a significant difference between the mean total scores of nurses’ performance and its dimension before and after the intervention (p < 0.001). The results of ANOVA before the intervention showed that there was a significant difference between the mean (SD) scores of care [63.14 (13.08), t = 13.66], pharmacologic [68.98 (13.15), t = 8.20], and electrical cardioversion dimensions [63.37 (10.47), t = 16.82, p < 0.001]. The results of ANOVA showed that the mean (SD) scores of the all dimensions did not differ significantly after the intervention [82.91 (9.75), 84.95 (83.87), and 83.51 (8.07), respectively, p > 0.05].

Conclusions:

The clinical supervision model can be used as an educational model combined with supervision to improve nurses’ performance in providing care to patients with AF.

A Web-Based Integrated Management Program for Improving Medication Adherence and Quality of Life, and Reducing Readmission in Patients With Atrial Fibrillation: Randomized Controlled Trial

BACKGROUND

Atrial fibrillation (AF) is related to a variety of chronic diseases and life-threatening complications. It is estimated that by 2050, there will be 72 million patients with AF in Asia, of which 2.9 million will have AF-associated stroke. AF has become a major issue for health care systems.

OBJECTIVE

We aimed to evaluate the effects of a web-based integrated management program on improving coping strategies, medication adherence, and health-related quality of life (HRQoL) in patients with AF, and to detect the effect on decreasing readmission events.

METHODS

The parallel-group, single-blind, prospective randomized controlled trial recruited patients with AF from a medical center in northern Taiwan and divided them randomly into intervention and control groups. Patients in the intervention group received the web-based integrated management program, whereas those in the control group received usual care. The measurement tools included the Brief Coping Orientation to Problems Experienced (COPE) scale, Medication Adherence Rating Scale (MARS), the three-level version of the EuroQoL five-dimension self-report questionnaire (EQ-5D-3L), and readmission events 2 years after initiating the intervention. Data were collected at 4 instances (baseline, 1 month, 3 months, and 6 months after initiating the intervention), and analyzed with generalized estimating equations (GEEs).

RESULTS

A total of 231 patients were recruited and allocated into an intervention (n=115) or control (n=116) group. The mean age of participants was 73.08 (SD 11.71) years. Most participants were diagnosed with paroxysmal AF (171/231, 74%), and the most frequent comorbidity was hypertension (162/231, 70.1%). Compared with the control group, the intervention group showed significantly greater improvement in approach coping strategies, medication adherence, and HRQoL at 1, 3, and 6 months (all P<.05). In addition, the intervention group showed significantly fewer readmission events within 2 years (OR 0.406, P=.03), compared with the control group.

CONCLUSIONS

The web-based integrated management program can significantly improve patients' coping strategy and medication adherence. Therefore, it can empower patients to maintain disease stability, which is a major factor in improving their HRQoL and reducing readmission events within 2 years.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04813094; https://clinicaltrials.gov/ct2/show/NCT04813094.

Development and validation of a Screening Tool to Evaluate and Warrant Anticoagulation Treatment prior to Discharge in inpatients with Atrial Fibrillation (STEWARxD-AF)

OBJECTIVE

Anticoagulation is highly effective for stroke prevention in atrial fibrillation (AF), reducing the risk by about 64%. Despite overwhelming evidence in support of anticoagulation, up to 40% of AF patients remain untreated. We aimed to develop and validate STEWAR_xD-AF: a Screening Tool to Evaluate and Warrant Anticoagulation Treatment prior to Discharge in Atrial Fibrillation.

MATERIALS AND METHODS

STEWAR_xD-AF was developed by integrating information extracted from the electronic health record (EHR). A stepwise decision process was applied, based on AF diagnosis, estimated CHA₂DS₂-VASc-score and anticoagulant use. A priority score was assigned accordingly, ranging from 0 (no risk) to 5 (highest risk of undertreatment). A cross-sectional study was performed to assess the accuracy of STEWAR_xD-AF. Criterion and tool validity were ascertained by determining sensitivity and specificity, compared to a manual check of the EHR in an inpatient sample (n = 800). Consistency regarding the priority score was determined by estimating Cohen's kappa.

RESULTS

A tool to screen for un(der)treated AF was developed and embedded into the EHR. Sensitivity and specificity for AF diagnosis were 98.4% and 87.6%, respectively. Overall sensitivity and specificity for identification of a CHA₂DS₂-VASc-score ≥ 2 was 97.7% and 72.7%. Sensitivity and specificity to determine the presence of anticoagulant treatment was at least 87.8% and 97.1% There was good agreement for the priority score (κ 0.74 (unweighted); 0.66 (weighted)).

CONCLUSIONS

STEWAR_xD-AF was able to identify untreated AF inpatients reliably and with a high sensitivity. Nearly no patients were missed. We will now implement this AF-screening tool in clinical practice to improve the use of anticoagulation and reduce the risk of stroke.

Progress and challenges for advanced practice nursing in Mexico and the United Kingdom

AIM

The aim of this study is to compare the advanced practice nursing development in Mexico with the United Kingdom.

BACKGROUND

In spite of the involvement of global and local bodies to establish and develop advanced practice nursing worldwide, progress remains variable due to the lack of homogeneity in health care systems and policies.

EVALUATION

Using thematic analysis from interviews of 29 health care professionals in Mexico, we identified four major issues that impact on the development of advanced practice nursing: (a) workforce, (b) organizational and institutional, (c) regulatory and legal and (d) academic and educational.

KEY ISSUES

Learning from the UK experience in relation to overcoming some of these issues has been insightful in terms of how advanced practice nursing skills in Mexican nurses can be developed.

CONCLUSIONS

Mexico is still in early stages of the development of APN. Based on the UK experience, the government may have to move forward to support higher level training, create labour market positions, establish new nursing functions, promote task-shifting and particularly implement solid regulation.

IMPLICATIONS FOR NURSING MANAGEMENT

The development of advanced practice nursing represents important challenges for training and practice of nursing in Mexico and the United Kingdom; therefore, interested actors will have to reach key agreements that could work as the foundations of an assertive planning process.

Nursing self-efficacy for oral anticoagulant therapy management: Development and initial validation of a theory-grounded scale

AIM

This study aimed to develop and validate a nursing self-efficacy scale for OAC management (SE-OAM).

BACKGROUND

Oral anticoagulant therapy (OAC) requires specific nursing competencies. Given that self-efficacy acts as a proxy assessment of nursing competence, its measurement is pivotal for addressing educational programs to enhance nursing competence in managing OAC. Thus far, the measurement of self-efficacy in OAC is undermined by the unavailability of valid and reliable tools.

METHODS

A multi-method and multi-phase design was adopted: Phase one was a methodological study encompassing developmental tasks for generating items. Phase two comprised the validation process for determining the content validity, construct and concurrent validity, and internal consistency through two cross-sectional data collections.

RESULTS

In total, 190 nurses were enrolled for determining the psychometric structure of the SE-OAM through an exploratory approach, and 345 nurses were subsequently enrolled to corroborate its most plausible factor structure derived from the exploratory analysis. The SE-OAM showed evidence of face and content validity, adequate construct, concurrent validity, good internal consistency, and stability. The final version of the scale encompassed 21 items kept by five domains: clinical management, care management, education, clinical monitoring, and care monitoring.

CONCLUSIONS

The SE-OAM showed evidence of initial validity and reliability, fulfilling a current gap in the availability of tools for measuring nursing self-efficacy in managing OAC. SE-OAM could be strategic for performing research to improve the quality of OAC management by enhancing nursing self-efficacy.

A nurse-led atrial fibrillation clinic: Impact on anticoagulation therapy and clinical outcomes

BACKGROUND

Nurses play a central role in the management of atrial fibrillation (AF) patients. An unresolved question is whether a nurse-led clinic would improve clinical outcomes. Herein, we investigated the impact of a nurse-led clinic on anticoagulation therapy and clinical outcomes in a cohort of naïve AF patients.

METHODS

Prospective study including AF patients starting vitamin K antagonists (VKAs) into a nurse-led AF clinic. These patients were followed in this specific AF clinic. Additionally, AF patients already taking VKAs for 6 months followed according to the routine clinical practice were included as comparison group. The quality of anticoagulation was assessed at 6 months. Efficacy and safety endpoints were recorded during follow-up.

RESULTS

We included 223 patients (Nurse-led clinic: 107; Usual care: 116). The mean time in therapeutic range and the proportion of INRs within the therapeutic range were similar in both groups. During 2.06 (IQR 1.01-2.94) years of follow-up, 64 (28.7%) patients changed to direct-acting oral anticoagulants. The proportion of switchers was higher in the nurse-led clinic (37.4%) than in the usual care group (20.7%) (P = .006) and these patients spent less time to switch (2.0 [IQR 0.7-2.9] vs 6.0 [IQR 3.7-11.2] years; P < .001). Importantly, the annual rate of ischaemic stroke/TIA was significantly lower in the nurse-led clinic (0.47%/year vs 3.88%/year, P = .016), without differences in safety endpoints.

CONCLUSION

A nurse-led AF clinic may offer a "patient-centered" review and holistic follow-up, and it would be associated with a reduction of ischaemic stroke/TIA, without increasing bleeding complications. Further studies should confirm these results.

Coordination of a remote mHealth infrastructure for atrial fibrillation management during COVID-19 and beyond: TeleCheck-AF

During the coronavirus 2019 (COVID-19) pandemic, outpatient visits for patients with atrial fibrillation (AF), were converted into teleconsultations. As a response to this, a novel mobile health (mHealth) intervention was developed to support these teleconsultations with AF patients: TeleCheck-AF. This approach incorporates three fundamental components: 1) “Tele”: A structured teleconsultation. 2) “Check”: An app-based on-demand heart rate and rhythm monitoring infrastructure. 3) “AF”: comprehensive AF management.

This report highlights the significant importance of coordination of the TeleCheck-AF approach at multiple levels and underlines the importance of streamlining care processes provided by a multidisciplinary team, using an mHealth intervention, during the COVID-19 pandemic. Moreover, this report reflects on how the TeleCheck-AF approach has contributed to strengthening the health system in maintaining management of this prevalent sustained cardiac arrhythmia, whilst keeping patients out of hospital, during the pandemic and beyond.

Variations in follow-up after atrial fibrillation ablation

BACKGROUND

A multidisciplinary patient-centered approach using evidence-based care is recommended in recent atrial fibrillation (AF) guidelines to achieve quality patient outcomes. Professional society guidelines are conflicting and vague in recommendations on timing of follow-up after AF ablation.

PURPOSE

The aim of this secondary analysis was to examine whether the type and timing of follow-up care after AF ablation affected patient outcomes.

METHODS

A 2-year, longitudinal, pilot study to explore patient experiences during the first 6 months following an AF ablation was conducted. Patients completed surveys and phone interviews before ablation, and at 1, 3, and 6 months after the ablation. Pearson correlations and repeated-measures analysis of variance were used for comparison of outcomes over time.

RESULTS

The sample (N = 20) had a mean age of 65 (± 7) years, was 55% female, 35% paroxysmal AF, and 65% persistent AF pre-ablation. Timing of follow-up visits following AF ablation varied widely. Patients reported many concerns and difficulties reflecting the lack of knowledge and unrealistic expectations of post-ablation recovery. Better outcomes were noted in those who were seen at 1-week post-ablation by a nurse practitioner (NP) compared with those who were not seen until 1 or 3 months after ablation by a physician.

IMPLICATIONS FOR PRACTICE

Atrial fibrillation ablation is routinely performed in the United States, yet there seems to be a lack of standardization concerning the type and timing of follow-up care after AF ablation. These preliminary findings support a standardized approach to include an NP visit at one week after AF ablation to achieve quality AF patient outcomes.

The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation

The current manuscript is the second update of the original Practical Guide, published in 2013 [Heidbuchel et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace 2013;15:625-651; Heidbuchel et al. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015;17:1467-1507]. Non-vitamin K antagonist oral anticoagulants (NOACs) are an alternative for vitamin K antagonists (VKAs) to prevent stroke in patients with atrial fibrillation (AF) and have emerged as the preferred choice, particularly in patients newly started on anticoagulation. Both physicians and patients are becoming more accustomed to the use of these drugs in clinical practice. However, many unresolved questions on how to optimally use these agents in specific clinical situations remain. The European Heart Rhythm Association (EHRA) set out to coordinate a unified way of informing physicians on the use of the different NOACs. A writing group identified 20 topics of concrete clinical scenarios for which practical answers were formulated, based on available evidence. The 20 topics are as follows i.e., (1) Eligibility for NOACs; (2) Practical start-up and follow-up scheme for patients on NOACs; (3) Ensuring adherence to prescribed oral anticoagulant intake; (4) Switching between anticoagulant regimens; (5) Pharmacokinetics and drug-drug interactions of NOACs; (6) NOACs in patients with chronic kidney or advanced liver disease; (7) How to measure the anticoagulant effect of NOACs; (8) NOAC plasma level measurement: rare indications, precautions, and potential pitfalls; (9) How to deal with dosing errors; (10) What to do if there is a (suspected) overdose without bleeding, or a clotting test is indicating a potential risk of bleeding; (11) Management of bleeding under NOAC therapy; (12) Patients undergoing a planned invasive procedure, surgery or ablation; (13) Patients requiring an urgent surgical intervention; (14) Patients with AF and coronary artery disease; (15) Avoiding confusion with NOAC dosing across indications; (16) Cardioversion in a NOAC-treated patient; (17) AF patients presenting with acute stroke while on NOACs; (18) NOACs in special situations; (19) Anticoagulation in AF patients with a malignancy; and (20) Optimizing dose adjustments of VKA. Additional information and downloads of the text and anticoagulation cards in different languages can be found on an EHRA website (www.NOACforAF.eu).

Persistence and outcomes of non-vitamin K antagonist oral anticoagulants versus warfarin in patients with non-valvular atrial fibrillation

AIMS AND OBJECTIVES

To compare persistence and outcomes of non-vitamin K antagonist oral anticoagulants (NOACs) versus warfarin in Chinese patients with non-valvular atrial fibrillation (AF).

BACKGROUND

Given the unpredictable warfarin response and the costliness of NOACs, more research is needed to clarify which drug enjoys better persistence and outcomes, helping to provide personalised care for patients.

DESIGN

A prospective cohort study.

METHODS

Chinese patients taking NOACs or warfarin from March 2016-April 2018 were followed up by telephone or outpatient visit at 3, 6 months and half a year thereafter. Anticoagulant persistence and outcomes including stroke and bleeding were collected. We used Cox regression to analyse data. This study was reported according to the STROBE guideline.

RESULTS

A total of 344 patients were enrolled; 146 patients received NOACs including dabigatran and rivaroxaban, and 198 patients received warfarin. Persistence with anticoagulants was low and dropped sharply at the third month. Patients on NOACs had worse persistence at 3, 6 and 12 months than those on warfarin. There was no difference in the incidence of ischaemic stroke and bleeding between groups, although ischaemic stroke and major bleeding occurred less frequently in the NOACs group. Paroxysmal AF, no heart failure and no stroke were predictors of NOACs non-persistence. Prior catheter ablation and no diabetes were associated with poor persistence of warfarin. The main reason for anticoagulant cessation was patient preference.

CONCLUSIONS

Chinese patients taking NOACs had lower persistence, similar rate of ischaemic stroke and bleeding compared with those on warfarin. Further inventions are needed to improve persistence in Chinese patients on NOACs.

RELEVANCE TO CLINICAL PRACTICE

Anticoagulation should highlight both persistence and outcomes emphasising personalised care of different drugs. Further interventions to improve persistence should be developed based on causes and risk factors and carried out in the third month of therapy.

Augmenting Atrial Fibrillation Care After an Emergency Department Visit: Implementing Telephone Practice

BACKGROUND

Between 2010 and 2012, the Heart Rhythm team in a tertiary care hospital completed a retrospective study that found that atrial fibrillation (AF) care can be episodic and heavily reliant on hospital resources, particularly the emergency department (ED).

PROBLEM

Patients who attend the ED with AF are at high risk of hospital admission.

APPROACH

A nurse practitioner (NP) was added to the Heart Rhythm team to create a program to improve AF care after an ED visit. Telephone practice was one of the many processes created.

OUTCOMES

Findings revealed that 37 of 90 patients presented to the ED with AF prior to telephone contact and 7 of 90 patients did so post-telephone contact (P < .001).

CONCLUSION

Telephone practice led by an NP provides an opportunity to improve assessment and management of patient with AF and offers a promising cost-effective method to reduce ED visits in the AF patient population.

Effect of reinforced, targeted in-person education using the Jessa Atrial fibrillation Knowledge Questionnaire in patients with atrial fibrillation: A randomized controlled trial

BACKGROUND

The knowledge level of atrial fibrillation patients about their arrhythmia, its consequences and treatment is poor. The best strategy to provide education is unknown.

AIM

To investigate the effect of reinforced targeted in-person education using the Jessa Atrial fibrillation Knowledge Questionnaire (JAKQ).

METHODS

Sixty-seven atrial fibrillation patients were randomized to standard care (including brochures) or targeted education. Follow-up visits were scheduled after one, three, six and 12 months. Targeted education during each visit focused on the knowledge gaps revealed by the JAKQ. Patients completed two questionnaires to assess their quality of life and symptom profile. Adherence to non-vitamin K antagonist oral anticoagulants was measured using electronic monitoring.

RESULTS

Sixty-two patients (31 education; 31 standard care) completed follow-up. Median baseline score on the JAKQ was similar in education (62.5%) and standard care group (56.3%; p=0.815). The intervention group scored significantly better over time (one month: 75.0%, 12 months: 87.5%; p<0.001) whereas there was no significant improvement in the control group (one month: 62.5%, 12 months: 62.5%; p=0.085). Providing targeted education after completion of the JAKQ required on average 6.9±4.6 min. Some improvements in quality of life, symptom burden and adherence were shown, without significant differences between the two groups ( p-values between 0.282 and 0.677).

CONCLUSION

The JAKQ is an effective tool for providing individualized education. A first targeted educational session significantly improved patients' knowledge level. Additional educational sessions maintained and strengthened this effect. A larger scale study is warranted to evaluate the impact on adherence and outcome measures.

Preparation for and Implementation of Shared Medical Appointments to Improve Self-Management, Knowledge, and Care Quality Among Patients With Atrial Fibrillation

Atrial fibrillation (AF) is the most common cardiac arrhythmia in adults and is associated with an increased risk of stroke, heart failure, and death. Therapy for this pervasive arrhythmia is complex, involving multiple options that chiefly manage symptoms and prevent stroke. Current therapeutic strategies are also of limited efficacy, and can present potentially life-threatening side effects and/or complications. Emerging research suggests that the burden of AF can be reduced by improving patient understanding of the arrhythmia and teaching patients to adopt and maintain lifestyle and behavior changes. Shared medical appointments (SMAs) have been successfully used to deliver education and develop patient coping and disease management skills for patients with complex needs, but there is a paucity of studies examining the use of SMAs for managing AF. Moreover, few studies have examined strategies for implementing SMAs into routine clinical care. We detail our approach for (1) adapting a patient-centered SMA curriculum; (2) designing an evaluation comparing SMAs to routine care on patient outcomes; and (3) implementing SMAs into routine clinical practice. We conclude that evaluation and implementation of SMAs into routine clinical practice requires considerable planning and continuous engagement from committed key stakeholders, including patients, family members, schedulers, clinical staff, nurse educators, administrators, and billing specialists.

Adherence, knowledge, and perception about oral anticoagulants in patients with atrial fibrillation at high risk for thromboembolic events after radiofrequency ablation

AIMS

This study aimed to: (a) determine adherence rates to oral anticoagulants in atrial fibrillation patients with a high risk for thromboembolic events postradiofrequency ablation; (b) evaluate patients' knowledge and perceptions towards oral anticoagulants; and (c) explore the impact of patients' knowledge and perceptions on treatment adherence.

BACKGROUND

Atrial fibrillation is a common arrhythmia associated with an increased risk of developing thromboembolic events such as stroke. Although adherence to oral anticoagulants is crucial to prevent such complications, the relationship between adherence, knowledge and patient perceptions is poorly understood in patients with atrial fibrillation at high risk for thromboembolic events after radiofrequency ablation.

DESIGN

A cross-sectional observational survey study was performed in a single centre.

METHODS

The levels of adherence, knowledge, and perception towards oral anticoagulants were assessed using the 8-item Morisky Medication Adherence Scale, Knowledge of Oral Anticoagulation Tool, Perception of Anticoagulant Treatment Questionnaire and Benefit-Risk Perception Tool, respectively. Results from these self-reported tools were analysed descriptively. A multivariable binary logistic regression model was used to identify factors associated with levels of adequate adherence.

RESULTS

Adequate treatment adherence was found in three-quarters of patients. The total mean knowledge score was low. Participants expressed high ease of use and low burden of treatment. Higher total knowledge and satisfaction scores were significant factors associated with higher levels of adherence.

CONCLUSION

There remains a huge unmet need to follow-up and educate patients with atrial fibrillation, focusing on good knowledge and correct perception of the advantages and disadvantages of oral anticoagulants. Our results suggest that increased knowledge and satisfaction rates might have a positive impact on adherence to oral anticoagulants.

Integrating new approaches to atrial fibrillation management: the 6th AFNET/EHRA Consensus Conference

There are major challenges ahead for clinicians treating patients with atrial fibrillation (AF). The population with AF is expected to expand considerably and yet, apart from anticoagulation, therapies used in AF have not been shown to consistently impact on mortality or reduce adverse cardiovascular events. New approaches to AF management, including the use of novel technologies and structured, integrated care, have the potential to enhance clinical phenotyping or result in better treatment selection and stratified therapy. Here, we report the outcomes of the 6th Consensus Conference of the Atrial Fibrillation Network (AFNET) and the European Heart Rhythm Association (EHRA), held at the European Society of Cardiology Heart House in Sophia Antipolis, France, 17-19 January 2017. Sixty-two global specialists in AF and 13 industry partners met to develop innovative solutions based on new approaches to screening and diagnosis, enhancing integration of AF care, developing clinical pathways for treating complex patients, improving stroke prevention strategies, and better patient selection for heart rate and rhythm control. Ultimately, these approaches can lead to better outcomes for patients with AF.

Risk Factor Management in Atrial Fibrillation

Atrial fibrillation (AF) is the most common clinical arrhythmia and is associated with increased morbidity and mortality. There is growing evidence that numerous cardiovascular diseases and risk factors are associated with incident AF and that lone AF is rare. Beyond oral anticoagulant therapy, rate and rhythm control, therapy targeting risk factors and underlying conditions is an emerging AF management strategy that warrants better implementation in clinical practice. This review describes current evidence regarding the association between known modifiable risk factors and underlying conditions and the development and progression of AF. It discusses evidence for the early management of underlying conditions to improve AF outcomes. It also provides perspective on the implementation of tailored AF management in daily clinical practice.

The future of atrial fibrillation management: integrated care and stratified therapy

Atrial fibrillation is one of the major cardiovascular health problems: it is a common, chronic condition, affecting 2-3% of the population in Europe and the USA and requiring 1-3% of health-care expenditure as a result of stroke, sudden death, heart failure, unplanned hospital admissions, and other complications. Early diagnosis of atrial fibrillation, ideally before the first complication occurs, remains a challenge, as shown by patients who are only diagnosed with the condition when admitted to hospital for acute cardiac decompensation or stroke. Once diagnosed, atrial fibrillation requires chronic, multidimensional management in five domains (acute management, treatment of underlying and concomitant cardiovascular conditions, stroke prevention therapy, rate control, and rhythm control). The consistent provision of these treatment options to all patients with atrial fibrillation is difficult, despite recent improvements in organisation of care, knowledge about atrial fibrillation, and treatment options. Integrated care models that provide patient-centred care in, or close to, the patient's community while maintaining access to all specialist treatment options, emerge as the best approach to achieve consistent delivery of these chronic treatments to all patients with atrial fibrillation. Ongoing research efforts will establish when to initiate oral anticoagulation in patients with device-detected atrial high-rate episodes, quantify the prognostic effect of early and comprehensive rhythm control therapy, including atrial fibrillation ablation, and delineate optimum methods to reduce bleeding complications in patients treated with anticoagulation. Additionally, research efforts are needed to define different types of atrial fibrillation on the basis of the main causes of atrial fibrillation to pave the way for the clinical development of stratified atrial fibrillation therapy.

ANMCO Position Paper: direct oral anticoagulants for stroke prevention in atrial fibrillation: clinical scenarios and future perspectives

It is now 4 years since the introduction of the new direct oral anticoagulants into clinical practice. Therefore, the Italian Association of Hospital Cardiologists (ANMCO) has deemed necessary to update the previous position paper on the prevention of thrombo-embolic complications in patients with non-valvular atrial fibrillation, which was published in 2013. All available scientific evidence has been reviewed, focusing on data derived from both clinical trials and observational registries. In addition, all issues relevant to the practical clinical management of oral anticoagulation with the new direct inhibitors have been considered. Specific clinical pathways for optimal use of oral anticoagulation with the new directly acting agents are also developed and proposed for clinical implementation. Special attention is finally paid to the development of clinical algorithms for medium and long-term follow-up of patients treated with new oral direct anticoagulants.

A practical approach to the new oral anticoagulants used for stroke prevention in patients with atrial fibrillation

This review evaluates the research undertaken in the last six years on the use of new oral anticoagulants for stroke prevention in atrial fibrillation and provides evidence-based answers to common clinical questions. Two types of new oral anticoagulants - direct thrombin (IIa) inhibitors, and Xa inhibitors - are currently available. These drugs have similar pharmacokinetics and pharmacodynamics. They are more predictable than, though in many respects comparable to, warfarin. They do not require frequent laboratory tests, nor do they have a narrow therapeutic window. When a patient requires surgery, new oral anticoagulants are easier to manage than warfarin due to their short half-lives. Short half-lives reduce the length of bleeding events. Information obtained from risk calculators such as CHA2DS2-VASc and HAS-BLED should be considered before prescribing. New oral anticoagulants are useful in every day clinical practice, but there are complex factors that should be considered in each patient before prescribing to implement the best practice and achieve the best results.

Adherence to oral anticoagulant therapy in patients with atrial fibrillation. Focus on non-vitamin K antagonist oral anticoagulants

Oral anticoagulation is pivotal in the management of thromboembolic risk in non-valvular atrial fibrillation (NVAF) patients. Effective anticoagulation is important to avoid major adverse events and medication adherence is central to achieve good anticoagulation control. Non-vitamin K antagonist oral anticoagulants (NOACs) are as effective and safe as vitamin K antagonist (VKAs) in NVAF patients. Due to the absence of routine anticoagulation monitoring with NOACs treatment, concerns have been raised about patient's adherence to NOACs and real-life data demonstrates variability in adherence and persistence. A multi-level approach, including patients' preferences, factors determining physicians' prescribing habits and healthcare system infrastructure and support, is warranted to improve initiation and adherence of anticoagulants. Adherence to NOACs is paramount to achieve a clinical benefit. Implementation of educational programs and easy-to-use tools to identify patients most likely to be non-adherent to NOACs, are central issues in improving the quality of NVAF anticoagulation management.

Temporal Patterns and Predictors of Rate vs Rhythm Control in Patients Attending a Multidisciplinary Atrial Fibrillation Clinic

BACKGROUND

Contemporary trends in the selection of and persistence with rate vs rhythm control for atrial fibrillation (AF) are not well studied, particularly in the context of multidisciplinary AF clinics.

METHODS

The initial arrhythmia management strategy in 1031 consecutive patients attending a multidisciplinary AF clinic from 2005-2012 was analyzed.

RESULTS

The 397 (38.5%) patients initially treated with rhythm control were younger (57.4 ± 14 years vs 65.6 ± 13 years; P < 0.0001) and more likely to be men (64.5% vs 56.9%; P = 0.019). They also had fewer comorbidities, lower CHADS₂ (Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack) scores, and greater symptom burden. The proportion treated with rhythm control declined from 46.9% in 2005-2006 to 28.4% in 2012 (P for trend < 0.0001). Compared with those initially selecting rate control, patients treated with rhythm control required more frequent clinic encounters (7 [interquartile range {IQR}, 3-12] vs 3 [IQR, 2-7]; P < 0.001) and longer follow-up (266 days [IQR, 84-548 days] vs 99 days [IQR, 0-313 days]; P < 0.001). Younger age, absence of diabetes and sleep apnea, earlier treatment year, higher symptom burden, and rural residence were independently associated with rhythm control. Persistence with the initial treatment strategy was reduced in the rhythm-control group (P = 0.003).

CONCLUSIONS

Use of rhythm control as the initial arrhythmia management strategy for AF in a specialty AF clinic is declining. Rhythm control requires more intensive follow-up and was more likely to lead to a change in arrhythmia management strategy.

Association between the diagnosis of atrial fibrillation and aspects of health status: a Danish cross-sectional study

BACKGROUND

Caring for patients living with atrial fibrillation (AF) is expected to be an increasing challenge for the healthcare sector in the future. Inconclusive results on self-reported health-related quality of life and health status in patients living with AF have previously been reported, ranging from being similar to those observed in patients who have sustained and survived a myocardial infarction to not being different from those of healthy subjects. In these studies, gender differences were not taken into account.

AIM AND OBJECTIVE

To investigate the association between the diagnosis of atrial fibrillation and self-reported health status.

DESIGN

An observational, cross-sectional study was conducted using data from the Danish Diet, Cancer and Health cohort. Information on health status was obtained using the Danish version of the Short Form 36 version 2 questionnaire. The analyses were stratified on gender. In adjusted analysis, we considered potential confounding from comorbidity expressed by the Charlson Comorbidity Index and effect modification by age.

ETHICAL APPROVAL

The local ethical committees of Copenhagen and Frederiksberg municipalities (Approval no.: (KF) 01-345/93) approved the study.

RESULTS

We included 42 598 participants of whom 873 had a diagnosis of AF and/or atrial flutter. We found a lower adjusted physical component score among AF patients. No systematic differences in the mental component score (MCS) were observed.

CONCLUSION

Participants diagnosed with AF report a clinically and statistically significantly lower physical health component score. No systematic differences in the MCS were found when comparing with the remaining participants in the cohort. As healthcare professionals caring for patients living with AF are not always expecting patients living with AF to experience a burden from their disease, the individual patients' experience of their situation, feelings, preferences, symptoms and needs leading to physical limitations should always be articulated.

Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation

The current manuscript is an update of the original Practical Guide, published in June 2013[Heidbuchel H, Verhamme P, Alings M, Antz M, Hacke W, Oldgren J, et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace 2013;15:625-51; Heidbuchel H, Verhamme P, Alings M, Antz M, Hacke W, Oldgren J, et al. EHRA practical guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation: executive summary. Eur Heart J 2013;34:2094-106]. Non-vitamin K antagonist oral anticoagulants (NOACs) are an alternative for vitamin K antagonists (VKAs) to prevent stroke in patients with non-valvular atrial fibrillation (AF). Both physicians and patients have to learn how to use these drugs effectively and safely in clinical practice. Many unresolved questions on how to optimally use these drugs in specific clinical situations remain. The European Heart Rhythm Association set out to coordinate a unified way of informing physicians on the use of the different NOACs. A writing group defined what needs to be considered as 'non-valvular AF' and listed 15 topics of concrete clinical scenarios for which practical answers were formulated, based on available evidence. The 15 topics are (i) practical start-up and follow-up scheme for patients on NOACs; (ii) how to measure the anticoagulant effect of NOACs; (iii) drug-drug interactions and pharmacokinetics of NOACs; (iv) switching between anticoagulant regimens; (v) ensuring adherence of NOAC intake; (vi) how to deal with dosing errors; (vii) patients with chronic kidney disease; (viii) what to do if there is a (suspected) overdose without bleeding, or a clotting test is indicating a risk of bleeding?; (xi) management of bleeding complications; (x) patients undergoing a planned surgical intervention or ablation; (xi) patients undergoing an urgent surgical intervention; (xii) patients with AF and coronary artery disease; (xiii) cardioversion in a NOAC-treated patient; (xiv) patients presenting with acute stroke while on NOACs; and (xv) NOACs vs. VKAs in AF patients with a malignancy. Additional information and downloads of the text and anticoagulation cards in >16 languages can be found on an European Heart Rhythm Association web site (www.NOACforAF.eu).

Team-Based Care for Managing Cardiac Comorbidities in Heart Failure

The need for HF management is predicted to increase as the HF population ages. Balancing HF and the multiple cardiac comorbidities remains difficult for any single provider, but becomes Fig. 6. Five-year rates of death or urgent heart transplantation by deciles of total cholesterol in heart failure. (From Horwich TB, Fonarow GC, Hamilton MA, et al. Low serum total cholesterol is associated with marked increase in mortality in advanced heart failure. J Card Fail 2002;8(4):222; with permission.) easier with the involvement of a team. Collaboration between physicians, nurses, nurse practitioners, physician assistants, pharmacists, and other health care workers reduces the burden of care coordination and simultaneously improves delivery of care. Team-based approaches increase cost-effectiveness, reduce hospitalization rates, and equally important, give patients more resources and support, which research shows may ultimately improve compliance and outcomes.

Implementation of non-vitamin K antagonist oral anticoagulants in daily practice: the need for comprehensive education for professionals and patients

Non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly used for the prevention and treatment of venous thromboembolism and for stroke prevention in patients with atrial fibrillation. NOACs do not require routine coagulation monitoring, creating a challenge to established systems for patient follow-up based on regular blood tests. Healthcare professionals (HCPs) are required to cope with a mixture of patients receiving either a vitamin K antagonist or a NOAC for the same indications, and both professionals and patients require education about the newer drugs. A European working group convened to consider the challenges facing HCPs and healthcare systems in different countries and the educational gaps that hinder optimal patient management. Group members emphasised the need for regular follow-up and noted national, regional and local variations in set-up and resources for follow-up. Practical incorporation of NOACs into healthcare systems must adapt to these differences, and practical follow-up that works in some systems may not be able to be implemented in others. The initial prescriber of a NOAC should preferably be a true anticoagulation specialist, who can provide initial patient education and coordinate the follow-up. The long-term follow-up care of patients can be managed through specialist coagulation nurses, in a dedicated anticoagulation clinic or by general practitioners trained in NOAC use. The initial prescriber should be involved in educating those who perform the follow-up. Specialist nurses require access to tools, potentially including specific software, to guide systematic patient assessment and workflow. Problem cases should be referred for specialist advice, whereas in cases for which minimal specialist attention is required, the general practitioner could take responsibility for patient follow-up. Hospital departments and anticoagulation clinics should proactively engage with all downstream HCPs (including pharmacists) to ensure their participation in patient management and reinforcement of patient education at every opportunity. Ideally, (transmural) protocols for emergency situations should be developed. Last but not least, patients should be well-informed about their condition, the treatment, possible risk scenarios, including the consequences of non-adherence to prescribed therapy, and the organisation of follow-up care.

Prevalence and antithrombotic management of atrial fibrillation in hospitalised patients

OBJECTIVES

The objective of this study was to determine the prevalence of atrial fibrillation (AF) in a tertiary care centre, to describe the comorbidity profile of hospitalised patients with AF, and to evaluate the appropriateness of their maintenance antithrombotic management.

METHODS

In a cross-sectional, descriptive study, all consenting hospitalised patients from 36 wards in a University hospital (excluding critical care units, psychiatric, maternity and paediatric wards) received an ECG on a single day. Also their charts were reviewed for key demographic and clinical data. For patients with AF, all factors and comorbidities comprising thromboembolic (CHA₂DS₂-VASc) and bleeding risk (HAS-BLED) were listed. The appropriateness of long-term anticoagulant therapy was assessed according to the 2010 international guidelines (CHA₂DS₂-VASc score 0=aspirin or no antithrombotic treatment; 1=aspirin or oral anticoagulant treatment (OAC); ≥2=OAC). The response rate was 79.7%, that is, an ECG was performed in 636 of 812 eligible hospitalised patients.

RESULTS

AF was present on ECG in 58 patients reflecting a 9.1% hospital point prevalence (95% CI 6.9% to 11.3%). Of the remaining 587 participants, 49 had a history of AF. Hence, 107 AF cases were identified, yielding a total prevalence of 16.8% (95% CI 13.9% to 19.7%). Patients with AF were detected in every hospital zone, with highest prevalence rates in zone 'thorax' (29.3% (95% CI 22.2% to 36.4%)) and 'internal medicine' (21.7% (95%CI 14.8% to 28.6%)). Patients with AF were older than patients without AF (78.7±10.3 years versus 62.7±15.9 years; p<0.001). The most common associated comorbidities were hypertension (63.6%) and valvular heart disease (58.9%). Most patients with AF were at high risk for stroke (CHA₂DS₂-VASc-score ≥2 in 92.5%). Overall, only 51.3% of all patients did receive appropriate anticoagulant long-term management, while 31% were undertreated and 17.7% were possibly overtreated.

CONCLUSIONS

This hospital-based study revealed high AF prevalence rates (16.8%). Patients with AF were present in all hospital zones and almost all patients were at high risk for stroke. Anticoagulation management was likely inappropriate in 48.7%, indicating the need for better guideline implementation initiatives to guarantee hospital-wide optimised care for patients with AF.

Integrated Chronic Care Management For Patients With Atrial Fibrillation - A Rationale For Redesigning Atrial Fibrillation Care

Atrial Fibrillation (AF) is a highly prevalent heart rhythm disturbance, often associated with underlying (cardio)vascular disease. Due to this the management of AF is often complex and current practice calls for a more comprehensive, multifactorial and patient-centred approach. Therefore an Integrated Chronic Care approach in AF was developed and implemented in terms of a nurse-led specialized outpatient clinic for patients with AF. A randomised controlled trial comparing the nurse-led approach with usual care demonstrated superiority in terms of cardiovascular hospitalization and death as well as cost-effectiveness in terms of Quality Adjusted Life Years (QALYs) and life years, in favour of the nurse-led approach. Implementing such approach can be difficult since daily practice can be persistent. To highlight the importance of integrated care wherein the nurse fulfils a significant role, and to provide a guide in developing and continuing such approach, this paper presents the theoretical framework of the AF-Clinic based on the principles of the Taxonomy for Integrated Chronic Atrial Fibrillation Management.