NursE led Atrial Fibrillation Management: The NEAT Study: A Randomized Controlled Trial

Assessing the impact of atrial fibrillation self-care interventions: A systematic review

This systematic review evaluates the efficacy of self-care interventions for atrial fibrillation (AF), focusing on strategies for maintenance, monitoring, and management applied individually or in combination. Adhering to the 2020 PRISMA guidelines, the search strategy spanned literature from 2005 to 2023, utilizing keywords and subject headings for "atrial fibrillation" and "self-care" combined with the Boolean operator AND. The databases searched included Medline, Embase, and CINAHL. The initial search, conducted on February 17, 2021, and updated on May 16, 2023, identified 5160 articles, from which 2864 unique titles and abstracts were screened. After abstract screening, 163 articles were reviewed in full text, resulting in 27 articles being selected for data extraction; these studies comprised both observational and randomized controlled trial designs. A key finding in our analysis reveals that self-care interventions, whether singular, dual, or integrated across all three components, resulted in significant improvements across patient-reported, clinical, and healthcare utilization outcomes compared to usual care. Educational interventions, often supported by in-person sessions or telephone follow-ups, emerged as a crucial element of effective AF self-care. Additionally, the integration of mobile and web-based technologies alongside personalized education showed promise in enhancing outcomes, although their full potential remains underexplored. This review highlights the importance of incorporating comprehensive, theory-informed self-care interventions into routine clinical practice and underscores the need for ongoing innovation and the implementation of evidence-based strategies. The integration of education and technology in AF self-care aligns with the recommendations of leading health organizations, advocating for patient-centered, technology-enhanced approaches to meet the evolving needs of the AF population.

Understanding for whom, under what conditions, and how an integrated approach to atrial fibrillation service delivery works: a realist review

AIMS

To understand for whom, under what conditions, and how an integrated approach to atrial fibrillation (AF) service delivery works (or does not work).

METHODS AND RESULTS

A realist review of integrated approaches to AF service delivery for adult populations aged ≥18 years. An expert panel developed an initial programme theory, searched and screened literature from four databases until October 2022, extracted and synthesized data using realist techniques to create context-mechanism-outcome configurations for integrated approaches to AF service, and developed an integrated approach refined programme theory. A total of 5433 documents were screened and 39 included. The refined programme theory included five context-mechanism-outcome configurations for how clinical and system-wide outcomes are affected by the way integrated approaches to AF service delivery are designed and delivered. This review identifies core mechanisms underpinning the already known fundamental components of integrated care. This includes having a central coordinator responsible for service organization to provide continuity of care across primary and secondary care ensuring services are patient centred. Additionally, a fifth pillar, lifestyle and risk factor reduction, should be recognized within an AF care pathway.

CONCLUSION

It is evident from our provisional theory that numerous factors need to interlink and interact over time to generate a successfully integrated model of care in AF. Stakeholders should embrace this complexity and acknowledge that the learnings from this review are integral to shaping future service delivery in the face of an aging population and increased prevalence of AF.

Effectiveness of cardiac rehabilitation programs on medication adherence in patients with cardiovascular disease: A systematic review and meta-analysis

Background

Education to improve medication adherence is one of the core components of cardiac rehabilitation (CR) programs. However, the evidence on the effectiveness of CR programs on medication adherence is conflicting. Therefore, we aimed to summarize the effectiveness of CR programs versus standard care on medication adherence in patients with cardiovascular disease.

Methods

A systematic review and meta-analysis was conducted. Seven databases and clinical trial registries were searched for published and unpublished articles from database inception to 09 Feb 2022. Only randomised controlled trials and quasi-experimental studies were included. Two independent reviewers conducted the screening, extraction, and appraisal. The JBI methodology for effectiveness reviews and PRISMA 2020 guidelines were followed. A statistical meta-analysis of included studies was pooled using RevMan version 5.4.1.

Results

In total 33 studies were included with 16,677 participants. CR programs increased medication adherence by 14 % (RR = 1.14; 95 % CI: 1.07 to 1.22; p = 0.0002) with low degree of evidence certainty. CR also lowered the risk of dying by 17 % (RR = 0.83; 95 % CI: 0.69 to 1.00; p = 0.05); primary care and emergency department visit by mean difference of 0.19 (SMD = -0.19; 95 % CI: -0.30 to -0.08; p = 0.0008); and improved quality of life by 0.93 (SMD = 0.93; 95 % CI: 0.38 to 1.49; p = 0.0010). But no significant difference was observed in lipid profiles, except with total cholesterol (SMD = -0.26; 95 % CI: -0.44 to -0.07; p = 0.006) and blood pressure levels.

Conclusions

CR improves medication adherence with a low degree of evidence certainty and non-significant changes in lipid and blood pressure levels. This result requires further investigation.

Does a nurse-led interventional program improve clinical outcomes in patients with atrial fibrillation? A meta-analysis

BACKGROUND

Being the most common type of arrhythmia, atrial fibrillation (AF) is progressively increasing with an annual rate of 5 million new cases. Recent guidelines highlight the importance of using collaborative multidisciplinary teams in order to improve outcomes during management of patients with AF. A nurse-led program including a nurse-directed education, counselling and intervention has shown to improve patients' outcomes in candidates with AF. In this analysis, we aimed to systematically compare the clinical outcomes observed in patients with AF who were assigned to a nurse-led interventional program versus a usual care group.

METHODS

EMBASE, MEDLINE, Http://www.

CLINICALTRIALS

gov , Web of Science; Google Scholar and Cochrane databases were the data sources. The clinical outcomes were considered as the endpoints in this study. This is a meta-analysis, and the statistical analysis was conducted by the RevMan software (version 5.4). Risk ratios (RR) with 95% confidence intervals (CI) were used to represent the data after statistical analysis.

RESULTS

Six studies with a total number 2916 participants were included whereby 1434 participants were assigned to a nurse-led intervention and 1482 participants were assigned to the usual care group. Our results showed that participants with AF who were assigned to the nurse-led interventional group had a significantly lower risk of composite endpoints (RR: 0.82, 95% CI: 0.70-0.96; P = 0.01), heart failure (RR: 0.66, 95% CI: 0.47-0.92; P = 0.02), atrial fibrillation (RR: 0.77, 95% CI: 0.63-0.94; P = 0.01) and re-admission (RR: 0.78, 95% CI: 0.62-0.99; P = 0.04). However, the risks of all-cause mortality (RR: 0.86, 95% CI: 0.68-1.09; P = 0.21), cardiac death (RR: 0.67, 95% CI: 0.33-1.39; P = 0.28), myocardial infarction (RR: 0.70, 95% CI: 0.35-1.42; P = 0.33), stroke (RR: 0.75, 95% CI: 0.44-1.26; P = 0.28), all bleeding events (RR: 1.11, 95% CI: 0.81-1.53; P = 0.51) and major bleeding events (RR: 0.91, 95% CI: 0.56-1.49; P = 0.71) were not significantly different.

CONCLUSIONS

The nurse-led interventional program significantly improved composite endpoints including heart failure and the recurrence of AF, resulting in a significantly lower admission rate compared to the usual care group. However, nurse-led interventional program did not affect mortality, stroke, myocardial infarction and bleeding events. Based on our current results, a nurse-led interventional programs apparently could be beneficial in patients with AF. Future larger trials would be able to confirm this hypothesis.

Effect of Multifactorial Risk Factor Interventions on Atrial Fibrillation: A Systematic Review and Meta-Analysis

Evidence supports the benefit of managing atrial fibrillation (AF) specific risk factors in secondary prevention of AF. However, a comprehensive summary of the effect of multifactorial risk factor interventions on outcomes of patients with AF over long-term is lacking. We searched MEDLINE, EMBASE, CINAHL, and Cochrane CENTRAL databases from inception to October 2021 for both randomized controlled trials (RCT) and observational studies comparing multifactorial risk factor interventions to usual care in patients with AF. Fifteen studies (10 RCT, 5 observational) with 3786 patients were included (mean age 63.8 years, 64.0% males). Follow-up ranged from 3 to 42 months. We found no significant effects of multifactorial risk factor interventions on AF recurrence [pooled relative risk (RR): 0.93, 95% CI: 0.74-1.16, P = 0.51, I² = 54%], AF-related rehospitalization at 12 months (RR: 0.69, 95% CI: 0.43-1.11, P= 0.13, I² = 0%), cardiovascular rehospitalization at 12 months (RR: 0.76, 95% CI: 0.53-1.09, P= 0.13, I² = 53%), or AF-related adverse events at 12 and 15 months. However, multifactorial interventions were associated with reduced AF-related symptoms and improved health-related quality of life (HRQoL) at all studied time points. Current evidence does not support consistent associations between multifactorial risk factor interventions and AF recurrence after rhythm control therapy or AF-related or cardiovascular hospitalization in patients with AF. However, these interventions are associated with clinically relevant improvement in AF-related symptoms and HRQoL. Additional randomized studies are required to evaluate the impact of multifactorial risk factor interventions on patient-centered health outcomes.

Prevalence of Postoperative Atrial Fibrillation and Impact to Nursing Practice—A Cross Sectional Study

Background: Atrial fibrillation is the most common clinically significant cardiac arrhythmia, and it might lead to heart failure, which prolongs the duration of hospitalization and consequently increases the cost of treatment. Thus, diagnosing and treating atrial fibrillation should be the first line of defense against further complications. This study aimed to determine the incidence rate of postoperative atrial fibrillation and correlation with cardiac surgery on heart valves. A specific aim was to determine the relationship between the prevalence of atrial fibrillation and socio-demographic features. Methods: The study has a prospective cross-sectional design. The questionnaire was anonymous, requesting socio-demographic information as inclusion criteria, and the data were analyzed using descriptive statistics methods. Results: The sample was 201 patients. χ2 test and t-test were performed where we found that the frequency of atrial fibrillation was higher in the groups that have had valve surgery compared to other cardiac surgeries (χ2 = 7.695, ss = 2, p = 0.021). Atrial fibrillation increased with the age of the patients, but the prevalence of atrial fibrillation was not correlated with body weight. Conclusion: The results of this this study show that atrial fibrillation was higher in the participants who had valve surgery compared to other cardiac surgeries. There was also an increase in atrial fibrillation in the older participants. The results of this study can help to improve nursing practice and the quality of care for cardiac surgery patients with regard to daily activities, or planning nursing care due to the patient’s condition.

Virtual Care Initiatives for Older Adults in Australia: Scoping Review

BACKGROUND

There has been a rapid shift toward the adoption of virtual health care services in Australia. It is unknown how widely virtual care has been implemented or evaluated for the care of older adults in Australia.

OBJECTIVE

We aimed to review the literature evaluating virtual care initiatives for older adults across a wide range of health conditions and modalities and identify key challenges and opportunities for wider adoption at both patient and system levels in Australia.

METHODS

A scoping review of the literature was conducted. We searched MEDLINE, Embase, PsycINFO, CINAHL, AgeLine, and gray literature (January 1, 2011, to March 8, 2021) to identify virtual care initiatives for older Australians (aged ≥65 years). The results were reported according to the World Health Organization's digital health evaluation framework.

RESULTS

Among the 6296 documents in the search results, we identified 94 that reported 80 unique virtual care initiatives. Most (69/80, 89%) were at the pilot stage and targeted community-dwelling older adults (64/79, 81%) with chronic diseases (52/80, 65%). The modes of delivery included videoconference, telephone, apps, device or monitoring systems, and web-based technologies. Most initiatives showed either similar or better health and behavioral outcomes compared with in-person care. The key barriers for wider adoption were physical, cognitive, or sensory impairment in older adults and staffing issues, legislative issues, and a lack of motivation among providers.

CONCLUSIONS

Virtual care is a viable model of care to address a wide range of health conditions among older adults in Australia. More embedded and integrative evaluations are needed to ensure that virtually enabled care can be used more widely by older Australians and health care providers.

Patients' experiences across the trajectory of atrial fibrillation: A qualitative systematic review

Aim

This study aimed to synthesize qualitative evidence on experiences of patients with atrial fibrillation (AF) during the course of diagnosis and treatment. We addressed three main questions: (a) What were the experiences of patients with AF during the course of diagnosis and treatment? (b) How did they respond to and cope with the disease? (c) What were the requirements during disease management?

Design

In this study, qualitative evidence synthesis was performed using the Thomas and Harden method.

Data Sources

Electronic databases, including PubMed, the Cochrane Library, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature, the China Biomedical Database, the WanFang Database, Chinese National Knowledge Infrastructure and VIP, were searched. The databases were searched from inception to August 2021.

Review Methods

Two researchers independently selected studies using qualitative assessment and review instruments for quality evaluation and thematic synthesis for the data analysis.

Results

A total of 2627 studies were identified in the initial search and 15 studies were included. Five analytical themes were generated: ‘Diagnosing AF’; ‘The impact of AF on the patients’; ‘Self‐reorientation in the therapeutic process’; ‘Living with AF and QoL’; and ‘External support to facilitate coping strategies.’

Conclusions

Our findings point out unique experiences of patients across the trajectory of AF related to delayed diagnosis, feelings of nonsupport, disappointment of repeated treatment failure and multiple distress associated with unpredictable symptoms. Future research and clinical practice are expected to improve the quality of medical diagnosis and treatment, optimize administrative strategy and provide diverse health support for patients with AF.

Impact

Understanding the experiences and needs of patients with AF in the entire disease process will inform future clinical practice in AF integrated management, which would be helpful in improving the professionalism and confidence of healthcare providers. In addition, our findings have implications for improving the effectiveness of AF diagnostic and treatment services.

Patient or Public Contribution

This paper presents a review of previous studies and did not involve patients or the public.

The interpretation of CHA2DS2-VASc score components in clinical practice: a joint survey by the European Heart Rhythm Association (EHRA) Scientific Initiatives Committee, the EHRA Young Electrophysiologists, the Association of Cardiovascular Nursing and Allied Professionals, and the European Society of Cardiology Council on Stroke

This European Heart Rhythm Association (EHRA) Scientific Initiatives Committee, EHRA Young Electrophysiologists, Association of Cardiovascular Nursing and Allied Professionals, and European Society of Cardiology (ESC) Council on Stroke joint survey aimed to assess the interpretation of the CHA2DS2-VASc score components and preferred resources for calculating the score. Of 439 respondents, most were general cardiologists (46.7%) or electrophysiologists (EPs) (42.1%). The overall adherence to the ESC-defined scoring criteria was good. Most variation was observed in the interpretation of the significance of left ventricular ejection fraction and brain natriuretic peptide in the scoring for the 'C' component, as well as the 'one-off high reading of blood pressure' to score on the 'H' component. Greater confidence was expressed in scoring the 'H' component (72.3%) compared with the 'C' (46.2%) and 'V' (45.9%) components. Respondents mainly relied on their recall for the scoring of CHA2DS2-VASc score (64.2%). The three most favoured referencing resources varied among different professionals, with pharmacists and physicians relying mainly on memory or web/mobile app, whereas nurses favoured using a web/mobile app followed by memory or guidelines/protocol. In conclusion, this survey revealed overall good adherence to the correct definition of each component in scoring of the 'C', 'H', and 'V' elements of the CHA2DS2-VASc score, although the variation in their interpretations warrants further clarifications. The preferred referencing resources to calculate the score varied among different healthcare professionals. Guideline education to healthcare professionals and updated and unified online/mobile scoring tools are suggested to improve the accuracy in scoring the CHA2DS2-VASc score.

Sense of Coherence and Quality of Life in Patients Treated with Antivitamin K Oral Anticoagulants: A Cross-Sectional Study

The aim of this study was to analyze the correlation between the participants’ self-reported quality of life and their sense of coherence in a sample (n = 85) of patients on treatment with oral antivitamin K anticoagulants. A cross-sectional design was used. The measurement instruments included a questionnaire on sociodemographic variables, the Spanish version of the Abbreviated World Health Organization Quality of Life questionnaire (WHOQOL-BREF), an oral-anticoagulant-treatment-specific quality-of-life questionnaire, and the sense-of-coherence (SOC) scale. We analyzed the correlations between the participants’ characteristics and the results from the quality-of-life and SOC scales. Age, level of education, employment status, living arrangement, and treatment length were the determinants of the quality of life in people treated with oral anticoagulants. We found a significant association between the four domains of the WHOQOL-BREF questionnaire and general treatment satisfaction (p < 0.01); no significant correlations were found between the SOC subscales and the oral-anticoagulant-treatment-specific quality of life in our sample. Women had a worse level of self-management than men. Nursing interventions should be tailored to the needs of the populations on treatment with oral anticoagulants in order to facilitate a higher level of self-management.

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.