C. Gallagher

Integrated care in atrial fibrillation: a systematic review and meta-analysis

Objective Atrial fibrillation (AF) is an emerging global epidemic associated with significant morbidity and mortality. Whilst other chronic cardiovascular conditions have demonstrated enhanced patient outcomes from coordinated systems of care, the use of this approach in AF is a comparatively new concept. Recent evidence has suggested that the integrated care approach may be of benefit in the AF population, yet has not been widely implemented in routine clinical practice. We sought to undertake a systematic review and meta-analysis to evaluate the impact of integrated care approaches to care delivery in the AF population on outcomes including mortality, hospitalisations, emergency department visits, cerebrovascular events and patient-reported outcomes. Methods PubMed, Embase and CINAHL databases were searched until February 2016 to identify papers addressing the impact of integrated care in the AF population. Three studies, with a total study population of 1383, were identified that compared integrated care approaches with usual care in AF populations. Results Use of this approach was associated with a reduction in all-cause mortality (OR 0.51, 95% CI 0.32 to 0.80, p=0.003) and cardiovascular hospitalisations (OR 0.58, 95% CI 0.44 to 0.77, p=0.0002) but did not significantly impact on AF-related hospitalisations (OR 0.82, 95% CI 0.56 to 1.19, p=0.29) or cerebrovascular events (OR 1.00, 95% CI 0.48 to 2.09, p=1.00). Conclusions The use of the integrated care approach in AF is associated with reduced cardiovascular hospitalisations and all-cause mortality. Further research is needed to identify optimal settings, methods and components of delivering integrated care to the burgeoning AF population.

Lifestyle management to prevent and treat atrial fibrillation

ABSTRACT Introduction: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia with a one in four lifetime risk in adults over the age of forty. Traditionally, AF management has focused on the three pillars of rate control, rhythm control and appropriate anticoagulation to reduce stroke risk. More recently, the importance of cardiovascular risk factor management in AF has emerged as a fourth and essential pillar with improved patient outcomes. Areas covered: Here, we aim to summarize the current available evidence for the association between various modifiable risk factors and AF, and to identify optimal treatment targets to improve outcomes. Expert Commentary: Care for AF patients utilizing an integrated approach and aggressive lifestyle management may reduce the enormous burden of this arrhythmia.

Alcohol and incident atrial fibrillation – A systematic review and meta-analysis

BACKGROUND Whilst high levels of alcohol consumption are known to be associated with atrial fibrillation (AF), it is unclear if any level of alcohol consumption can be recommended to prevent the onset of the condition. The aim of this review is to characterise the association between chronic alcohol intake and incident AF. METHODS AND RESULTS Electronic literature searches were undertaken using PubMed and Embase databases up to 1 February 2016 to identify studies examining the impact of alcohol on the risk of incident AF. Prospective studies reporting on at least three levels of alcohol intake and published in English were eligible for inclusion. Studies of a retrospective or case control design were excluded. The primary study outcome was development of incident AF. Consistent with previous studies, high levels of alcohol intake were associated with an increased incident AF risk (HR 1.34, 95% CI 1.20-1.49, p<0.001). Moderate levels of alcohol intake were associated with a heightened AF risk in males (HR 1.26, 95% CI 1.04-1.54, p=0.02) but not females (HR 1.03, 95% CI 0.86-1.25, p=0.74). Low alcohol intake, of up to 1 standard drink (SD) per day, was not associated with AF development (HR 0.95, 95% CI 0.85-1.06, p=0.37). CONCLUSIONS Low levels of alcohol intake are not associated with the development of AF. Gender differences exist in the association between moderate alcohol intake and AF with males demonstrating greater increases in risk, whilst high alcohol intake is associated with a heightened AF risk across both genders.

Atrial fibrillation and risk of hip fracture: A population-based analysis of 113,600 individuals

BACKGROUND A number of cardiovascular diseases have been linked with bone health and an increased risk of osteoporotic fracture. Whether atrial fibrillation (AF) is associated with subsequent fracture risk is not known. METHODS Administrative, clinical and hospitalisation information were linked over a 14-year period. From this longitudinal, population-based dataset of 113,600 individuals, time-dependent exposures using multivariate Cox proportional hazards regression models were employed to determine incidence rates and hazard ratios (HR) for hip fracture according to a history of AF. RESULTS The annualised incidence rate for hip fracture was 7.4 per 1000 person-years (95% CI 7.1-7.7) in those without AF and 17.5 per 1000 person-years (95% CI 16.8-18.1) in those with AF. Compared to individuals without AF, those with AF were more likely to develop incident hip fracture in both men (unadjusted HR 2.39 [95% CI 1.96-2.91]) and women (unadjusted HR 2.91 [95% CI 2.55-3.34]). After adjusting for potential confounders, these associations were attenuated but remained statistically significant (adjusted HR 1.97 [95% CI 1.61-2.42] in men; adjusted HR 2.08 [95% CI 1.80-2.39] in women). CONCLUSIONS A history of AF was associated with an increased risk of hip fracture in this large, population-based analysis. This association appeared to remain significant even after adjusting for potential confounders such as age, comorbidities and medication use. Patients with a history of AF may represent a clinical population in whom screening for and treatment of osteoporosis may be warranted to reduce the risk of subsequent fracture.

PREVEntion and regReSsive Effect of weight-loss and risk factor modification on Atrial Fibrillation: the REVERSE-AF study

Aims Atrial fibrillation (AF) is a progressive disease. Obesity is associated with progression of AF. This study evaluates the impact of weight and risk factor management (RFM) on progression of the AF. Methods and results As described in the Long-Term Effect of Goal-Directed Weight Management in an Atrial Fibrillation Cohort: A Long-Term Follow-Up (LEGACY) Study, of 1415 consecutive AF patients, 825 had body mass index ≥ 27 kg/m2 and were offered weight and RFM. After exclusion, 355 were included for analysis. Weight loss was categorized as: Group 1 (<3%), Group 2 (3-9%), and Group 3 (≥10%). Change in AF type was determined by clinical review and 7-day Holter yearly. Atrial fibrillation type was categorized as per the Heart Rhythm Society consensus. There were no differences in baseline characteristic or follow-up duration between groups (P = NS). In Group 1, 41% progressed from paroxysmal to persistent and 26% from persistent to paroxysmal or no AF. In Group 2, 32% progressed from paroxysmal to persistent and 49% reversed from persistent to paroxysmal or no AF. In Group 3, 3% progressed to persistent and 88% reversed from persistent to paroxysmal or no AF (P < 0.001). Increased weight loss was significantly associated with greater AF freedom: 45 (39%) in Group 1, 69 (67%) in Group 2, and 116 (86%) in Group 3 (P ≤ 0.001). Conclusion Obesity is associated with progression of the AF disease. This study demonstrates the dynamic relationship between weight/risk factors and AF. Weight-loss management and RFM reverses the type and natural progression of AF.

Postural tachycardia syndrome: current perspectives.

Postural tachycardia syndrome (POTS) is the combination of an exaggerated heart rate response to standing, in association with symptoms of lightheadedness or pre-syncope that improve when recumbent. The condition is often associated with fatigue and brain fog, resulting in significant disruptions at a critical time of diagnosis in adolescence and young adulthood. The heterogeneity of the underlying pathophysiology and the variable response to therapeutic interventions make management of this condition challenging for both patients and physicians alike. Here, we aim to review the factors and mechanisms that may contribute to the symptoms and signs of POTS and to present our perspectives on the clinical approach toward the diagnosis and management of this complex syndrome.

Ensuring adherence to therapy with anticoagulation in patients with atrial fibrillation

Atrial fibrillation (AF) is a significant burden for healthcare systems due to increased morbidity and mortality rates. It is a major cause of ischaemic stroke, which is considered one of the most serious and disabling complications of AF. Stroke prevention with oral anticoagulation (OAC) by vitamin K antagonists (VKA) or non-vitamin K antagonists (NOAC) is therefore a significant component of AF management. Both VKAs and NOACs are effective for the prevention of stroke in AF; however, stringent adherence to the recommended treatment regimen is crucial, both from a prescriber’s and a patient’s perspective. Worldwide, stroke prevention in AF is suboptimal, with poor adherence to international guideline recommendations.1 Poor adherence is a major barrier to effective stroke prevention, reflected in inadequate time in therapeutic range (TTR) with VKA treatment. A proposed advantage of NOAC therapy is the lack of requirement for routine blood monitoring for therapeutic levels. However, this fact, along with a short plasma half-life of approximately 12 hours, means that adherence to therapy becomes even more crucial, and indeed non-persistence or discontinuation of OAC treatment can have devastating consequences.2 In this issue of the Journal, Jackevicius et al 3 published their findings on early non-persistence (within 6 months after initiation) with dabigatran and rivaroxaban in patients with AF. A retrospective cohort study was performed using linked administrative data from hospital admissions in Ontario, Canada, over a time period of 16 years (1998–2014). This cohort comprised patients aged ≥65 years with a diagnosis of AF prior to NOAC prescription. Given that both dabigatran and rivaroxaban were available on formulary from 2012 in Canada, all patients were considered new users of …

Oral Anticoagulation Therapy in Atrial Fibrillation Patients Managed in the Emergency Department Compared to Cardiology Outpatient: Opportunities for Improved Outcomes

INTRODUCTION Recent registry data suggests oral anticoagulation (OAC) usage remains suboptimal in atrial fibrillation (AF) patients. The aim of our study was to determine if rates of appropriate use of OAC in individuals with AF differs between the emergency department (ED) and cardiac outpatient clinic (CO). METHODS This was a retrospective study of consecutive AF patients over a 12-month period. Data from clinical records, discharge summaries and outpatient letters were independently reviewed by two investigators. Appropriateness of OAC was assessed according to the CHA2DS2-VASc score. RESULTS Of 455 unique ED presentations with AF as a primary diagnosis, 115 patients who were treated and discharged from the ED were included. These were compared to 259 consecutively managed AF patients from the CO. Inappropriate OAC was significantly higher in the ED compared to the CO group (65 vs. 18%, p<0.001). Treatment in the ED was a significant multivariate predictor of inappropriate OAC (odds ratio 8.2 [4.8-17.7], p<0.001). CONCLUSIONS This patient level data highlights that significant opportunity exists to improve disparities in the use of guideline adherent therapy in the ED compared to CO. There is an urgent need for protocol-driven treatment in the ED or streamlined early follow-up in a specialised AF clinic to address this treatment gap.