In our department recently we have been discussing the issue of keeping up with contemporary practice guidelines to deliver best patient care. As I think with all NHS departments, with ever increasing workloads, high patient and referrer expectation (but slow or little progress with additional resource), how we achieve these goals in a sustainable way is going to be predictably challenging.
One of the areas we were reviewing is the new European Society guidelines on Atrial fibrillation, and a particular point of discussion was the idea of an AF Heart Team.
The ESC guidance is formed from an appropriately broad range of health professionals involved in the care of patients with AF. It highlights the involvement of community practitioners, geriatricians, stroke physicians/neurologists, and specialist nurses; as well as cardiologists and cardiac surgeons and the necessity for these specialities continuing contribution to AF patient care.
The concept of an AF heart team clearly isn’t that all these specialities will be in the same room to discuss every case, but instead means the need for an integrated care approach, which we haven’t had on a systematic basis to date.
The evidence seems quite clear that the integrated approach for patients with AF can make a significant impact on their progress and outcomes.
In 2014, my EP colleagues initially, and then the rest of us who refer to them a small group of our AF patients, were struck by the results of the Aggressive Risk Factor Reduction Study for Atrial Fibrillation and Implications for the Outcome of Ablation (ARREST-AF). The study showed us that risk factor management markedly improved the outcome of the procedure. The treatment arm in the study was seen in a dedicated physician-directed clinic which aimed to improve BP control; had support for a concentrated effort to achieve weight loss; had early referral specialist review for glycaemic control; and, assessed and referred patients for the treatment of obstructive sleep apnoea.
After the initial excitement, it has been clear that bringing this involvement together on a practical basis in the NHS, has been a little frustrating. Additional referrals to already busy services such as the sleep apnoea clinic, and who to refer to for concentrated efforts for weight reduction, remain issues. But, we are all clear how essential this is for the AF ablation patients, so we’ll need to discuss this further.
An integrated area which we can build on is the role of nurse-led, cardiologist supervised AF clinics. It is clear that these can improve guideline adherence, and impressively, improve outcomes, and are cost-effective. We already have our arrhythmia specialists nurses running our cardioversion service, including a follow-up clinic, and a service extension would obviously dovetail nicely. But, with more activity, we have the possibility of not having sufficient cover, with the inevitable tensions. Can we be persuasive enough to fund and attract more nurses for this area, especially when we already have resource stresses from other similarly deserving and evidence-based areas such as heart failure and ACHD? We’ll have to see.
As highlighted in the Heart editorial by Professor Paulus Kirchhof, different specialists can contribute in the five domains of AF care: acute rate and rhythm control; manage precipitating risk factors: assess stroke risk; assess heart rate; and assess symptoms. In effect, this would lead to a virtual MDT, with the support and co-ordination through the central point of the AF clinic and its practitioners.
There would still be a place for a more conventional MDT approach for the more difficult choices such as the potential use of LAA occlusion; although, we aren’t yet in a position to offer this. A feature of the in-room MDT discussion remains that generalists can be a steadying influence to proceduralists in moderating the natural enthusiasm for new technologies. Although it is notable that interventional EP doc John Mandrola has recently cautioned about the expansion of LAA occlusion and surgical AF ablation. My feeling is that LAA occluders will follow a similar path to PFO closure, with respect to their evidence-base and further application, but we’ll see.
Our group was clear that working to the new ESC guidance will lead to us being involved, and more involved, in more AF patients, and it is certain we will have more patients going forward to AF ablation, with the earlier selection of the PAF group who have most to gain by it. But, none of us could be definite about how many more that might be, and then the impact on our service provision. With waiting lists already under significant pressure, it would be beneficial to have a clearer idea. However, the patient need is clear and the evidence-base benefit seems to be too, so another challenge to rise to!