Integrated Management Approach to Atrial Fibrillation Care: A Cost Utility Analysis

BackgroundAtrial fibrillation (AF) is a substantial burden on health care. Combined specialist and nurse-based AF clinics are associated with improved outcomes. However, Canadian data on the cost-effectiveness of this integrated management approach to AF care are lacking.MethodsWe evaluated health care costs and outcomes of 413 patients with newly-diagnosed AF in 3 emergency departments in Nova Scotia between January 1, 2011 and January 31, 2014. Using a before-after study design, patients were divided into usual care (228 patients) and intervention (185 patients) groups. The intervention was a nurse-run, physician-supervised AF clinic. Costs and quality-adjusted life years (QALYs) were compared between usual care and intervention. Costs were those incurred because of the clinical outcome, bleeding events, medications, and cardiovascular-related procedures. Probabilistic analysis was conducted to assess uncertainty.ResultsThe AF clinic was associated with an average cost reduction of CAD$210.83 and an average improvement in QALY of 0.0007 per patient. The AF clinic was dominant over usual care despite higher operational and medication costs over 1 year. It provided greater cost-saving in approximately 66% of probabilistic analysis simulations and generated more QALYs in approximately 92% of simulations. An incremental cost-effectiveness ratio < $50,000 was found in 68% of simulations.ConclusionsThe present study provides guidance regarding the cost-effectiveness of an integrated management approach compared with usual specialty care of AF in a Canadian setting. We recommend further study be undertaken that prospectively plans for economic evaluation before definitive assessments of cost-effectiveness can be made.     

Use of Administrative Data to Monitor Cardiac Implantable Electronic Device Complications

Cardiac implantable electronic devices (CIEDs) are increasingly used in the Canadian population, because of expanding indications and an aging population. Device-related complications are a source of morbidity and mortality. There is currently no comprehensive monitoring strategy of CIED-related complications in Canada. The objective of this study was to determine the utility of administrative data in tracking CIED complications. This was a retrospective observational study in patients with newly implanted pacemakers, pacemaker system revisions, and implantable cardioverter defibrillators (ICDs) from 2011 to 2014. The study was performed at a single academic centre in Nova Scotia. A comprehensive chart review was used as the gold standard for device-related complications. This was compared with the reporting of complications identified in the Canadian Institute for Health Information Discharge Abstract Database and the National Ambulatory Care Reporting System Database (NACRS). Sensitivity and specificity of Canadian Institute for Health Information/NACRS was reported. There were 1327 patients included in the study (742 pacemakers, 585 ICDs). The rate of complications in the pacemaker population was 8.0%; the sensitivity of Discharge Abstract Database/NACRS for detection of these was 83.1%, and specificity 100%. The rate of complications in the ICD population was 12.0%, with a sensitivity of 92.1%, and specificity 100%. Thirty-day mortality was 1.8% in the pacemaker population, and 0.3% in the ICD population. This study provides feasibility for use of administrative data for detection of device-related complications, showing reasonable sensitivity and excellent specificity. Further work to determine generalizability of these data across Canada is required to ensure accurate monitoring of device-related complications.     

Canadian Registry of Implantable Electronic Device Outcomes: Surveillance of High-Voltage Leads

Background

Cardiac implantable electrical devices (CIEDs) are subject to advisories and complications that can result in morbidity and mortality for patients; there is currently no system in Canada to track these.

The Impact of Cardiac Rehabilitation on Mental and Physical Health in Patients With Atrial Fibrillation: A Matched Case-Control Study

Background

Patients with atrial fibrillation (AF) experience symptom burden, exercise intolerance, weight gain, poor mental health, and diminished quality of life (QoL). Cardiac rehabilitation (CR) is recommended for patients with heart disease, and its benefits are well established, yet clinical guidelines for patients with AF do not include the referral to CR.

The Effect of Cardiac Rehabilitation Attendance on Sexual Activity Outcomes in Cardiovascular Disease Patients: A Systematic Review

Background

Decreased sexual activity (SA) is a common problem in patients with cardiovascular disease (CVD). Although there is evidence that cardiac rehabilitation (CR) is effective in improving physical outcomes and overall quality of life, its effects on SA remain unclear. In this systematic review we assessed the association between CR attendance and SA outcomes in adults with CVD.

Characterization of Low-Voltage Areas in Patients With Atrial Fibrillation: Insights From High-Density Intracardiac Mapping

Background

There is limited data on the scar burden in patients with atrial fibrillation (AF). In this study, we sought to evaluate the presence and extent of an abnormal left atrial (LA) substrate in patients with paroxysmal or persistent AF.

Insights on Atrial Fibrillation in Congenital Heart Disease

Patients with congenital heart disease (CHD) have been surviving late into adulthood, with atrial arrhythmias being the most common long-term complication. In recent reports, atrial fibrillation (AF) tended to be the most common form of arrhythmias among groups of patients with adult CHD (ACHD) older than 50 years of age. When compared with their adult counterparts without CHD, AF in patients with ACHD has been characterized by a higher incidence and prevalence, younger age of onset, and a greater risk of progression to persistent AF. Risk factors for the development of AF are not well known but include older age, left atrial dilation, systemic hypertension, and multiple cardiac surgeries. Data on management options such as optimal antiarrhythmic drug therapy, indications for anticoagulation, and efficacy and safety of catheter ablation are limited. There is a crucial need for further research exploring management, prevention, and monitoring strategies for the growing ACHD patient population with AF. This report will provide a contemporary review of the epidemiology, pathophysiology, and management options for AF in this complex patient population.     

The Effect of Cardiac Rehabilitation on Health-Related Quality of Life in Patients With Coronary Artery Disease: A Meta-analysis

Background

The clinical effectiveness of cardiac rehabilitation (CR) on health-related quality of life (HRQOL) is an area that has not been consistently explored. The objective of this systematic review was to evaluate the effectiveness of providing any core component of CR on HRQOL domains.

Atrial Fibrillation and Heart Failure: Untangling a Modern Gordian Knot

Heart failure (HF) and atrial fibrillation (AF) share common risk factors and frequently coexist. Both are highly prevalent in our aging population, and mortality associated with the combination is significantly higher than for each alone. An intricate link exists between AF and HF, including interrelated mechanisms and pathophysiology. Asymptomatic left ventricular systolic or diastolic dysfunction can exacerbate or be exacerbated by AF, resulting in HF with reduced ejection fraction or preserved ejection fraction. A number of treatment strategies have improved symptoms, exercise tolerance, and quality of life for patients with HF, but few have resulted in alteration in prognosis. Sinus rhythm, achieved pharmacologically, has not altered important outcomes, including cardiovascular or total mortality in patients with HF. In recent studies, catheter ablation to achieve sinus rhythm seems to have a significant impact on symptoms, heart function, and possibly mortality. Until future studies can confirm or clarify the impact of catheter ablation on outcomes, the field remains cautious but optimistic that better treatment strategies for patients with HF with reduced ejection fraction or preserved ejection fraction are within reach.     

Antithrombotic Therapy for Atrial Fibrillation and Coronary Disease Demystified

Atrial fibrillation (AF) is a progressive chronic disease characterized by exacerbations and periods of remission. It is estimated that up to 20% to 30% of those with AF also have coronary artery disease (CAD), and 5% to 15% will require percutaneous coronary intervention (PCI). In patients with concomitant AF and CAD, management remains challenging and requires a careful and balanced assessment of the risk of bleeding against the anticipated impact on ischemic outcomes (AF-related stroke and systemic embolism, as well as ischemic coronary events). Oral anticoagulation (OAC) is indicated for the prevention of AF-related stroke and systemic embolism, whereas antiplatelet therapy is indicated for the prevention of coronary events. Each offers a relative efficacy benefit (dual antiplatelet therapy [DAPT] is more effective than OAC alone in reducing cardiovascular death, myocardial infarction, stent thrombosis, and ischemic coronary events in a population with acute coronary syndromes [ACS]), but with a relative compromise (DAPT is significantly inferior to OAC for the prevention of stroke/systemic embolism in an AF population at increased risk of stroke). The purpose of this review is to explore the current evidence and rationale for antithrombotic treatment strategies in patients with both AF and CAD. Specifically, there is a focus on how to best tailor the therapeutic choices (OAC and antiplatelet therapy) to individual patients based on their underlying coronary presentation.