In this interview we speak with Monica Pammer, PA-C, in electrophysiology at the Hospital of the University of Pennsylvania, about her recent research examining the use of novel oral anticoagulants (NOACs) on an “as needed basis” and guided by diligent pulse monitoring to detect recurrent atrial fibrillation (AF) and prevent stroke risk.
Tell us about some of the challenges associated with long-term oral anticoagulation therapy.
The main challenge is having patients take their medications — not everyone wants to take a blood thinner due to the associated risks such as bleeding. Active young people generally do not want to be on blood thinners because they like to participate in vigorous exercise and competitive sports which can increase their risk of injuries, so this can be dangerous if on a blood thinner. The other issue with anticoagulants is that for patients on warfarin, there are dietary restrictions and regular blood testing, and no one likes to get a needle stick every week. In addition, TV commercials about NOACs make our job a little more difficult because of all the potential side effects they advertise. There are risks, but we discuss these with patients, and ultimately it’s a decision between the provider and patient as to what is best. We counseled the patients on the guidelines for anticoagulation, and then a discussion with the patients ensues from there.
What were your reasons for deciding to try testing novel oral anticoagulants on an “as needed basis” alongside diligent pulse monitoring to detect recurrent AF?
These patients did not want to continue anticoagulation. Most of the patients in this study were post ablation or were from a small subset that used antiarrhythmic medications to control their arrhythmia. Despite a successful ablation or rhythm control with medications, they were still on anticoagulation. With the onset of action of the novel anticoagulants, we decided to try using them on an as needed basis on a very select patient population who were not interested in remaining on anticoagulation despite their stroke risk.
Describe implementation of this program in 2011. How did you become involved with AliveCor?
I found out about it online – I’m always looking for educational tools that assist patients with exercising, pulse monitoring, weight loss, etc. I use a lot of different modalities – in the beginning, I told patients to buy a stethoscope and listen to their heartbeat to make sure it was regular, as well as to take their pulse manually on their neck or wrist. As time went on, I recommended patients use an automated blood pressure machine in addition to taking their pulse manually. Then came the smartphone and its various apps, but they weren’t as sophisticated as doing an ECG or Holter monitor. When the FDA approved the AliveCor monitor, we decided to recommend it as an option to monitor their pulse. I want to state that transtelephonic monitoring or implantable loop recorders are our preferred monitoring to assess arrhythmia burden, and accessory tools that help patients monitor their pulse such as the AliveCor, apps, blood pressure machines, or Fitbits are secondary methods. If a patient fails any of our standard monitoring, meaning they have recurrence of atrial fibrillation, they are not a candidate for the study. If the cardiac monitors show no AF, and patient is compliant taking their pulse, then we suggest the as needed NOAC option. We utilize a very regimented and strict protocol in order to keep our patients safe, but they have to take ownership too. Our patients have to let us know that they’re taking their pulse, and need to show me how they take their pulse and count the beats while I’m taking their pulse with them. These patients are very motivated to try to get off blood thinners.
Patients had to manually take their pulse first and foremost. They could use another method along with it, but we always tell our patients that an electronic blood pressure machine is not the same as manually taking your blood pressure. They have to be comfortable taking their own pulse at least twice a day — apps can be used as an adjunct to their pulse taking. If they feel something suggestive of an arrhythmia, they can use the AliveCor monitor (Kardia app) at that moment and send me the ECG via email to go over what they’re feeling.
How many patients had to start an NOAC or had to transition back to chronic oral anticoagulation for recurrent AF episodes during follow-up?
There were 10 patients that transitioned back to chronic oral anticoagulation therapy. Twenty-six patients used a NOAC.
Is this use of NOACs on an “as needed” basis for AF still ongoing?
Yes, it’s still ongoing and something we’ve implemented into our practice, but it’s not officially written into our practice guidelines. In working with these motivated patients, Dr. Francis Marchlinski and I decided the initial goal was not to have them go off anticoagulation, but to teach these patients with AF how to take their pulse and monitor their arrhythmia. Especially with AF, it’s important that these patients know how to take their pulse, because nothing is 100% successful in life, and they may have little episodes that we need to know about and when they’re occurring. Our main goal was to make people aware of their health and their AF. Our other goal was to help these patients get through life a little easier without having to take a daily blood thinner and without increasing their stroke or bleeding risk.
The study that we presented included 100 patients, and we’re up to about 120 now. When I see patients in clinic who are 6 months to a year post ablation, they’ll bring up the subject with us that they want to discuss coming off anticoagulation. They’ll tell us they want to come off anticoagulation because they have a surgery coming up, or they want to go skiing, or that they’ve been doing great for a year and their monitor is showing no AF. We’re not seeking these patients out — they are seeking us. Our first recommendation to them is that they need to learn how to take their own pulse.
Did age play a role in patient compliance regarding use of technology?
It’s interesting – you might think that the older population (e.g., late 70s to early 80s) would not be as up to date on technology, but they are. I haven’t really seen much of an age discrepancy. I do think the younger population is more motivated to come off anticoagulation because their stroke risk is lower than people over the age of 65. However, patients’ motivation for monitoring their pulse was pretty much equally distributed throughout the age population.
This study started in 2011 with highly motivated patients. In 2016, would you say more patients fit this category now than ever? Do you find patients want a larger role in their own healthcare?
As a teaching hospital, we begin educating our patients about their health and disease process on day 1. We’re very diligent about educating our patients on how to be involved in their treatment and care for their arrhythmia. I think because our patients are so educated and involved in their care, they are more motivated to want to do what is best in order to lower their risks, take less medicines, and lower their risk of side effects from those medicines. A healthier lifestyle can lead to better outcomes for all health issues, whether it is high blood pressure, diabetes, or high cholesterol.
Do you find that patients are more interested nowadays in tools such as healthcare apps?
I think these are adjunct tools that patients can use to help them take better care of themselves. Patients are more conscious of their health, and want to know about anything and everything available that will help them be healthier — whether it’s an app, Fitbit, watch, or wristband. The app is an adjunct accessory that we use, but it’s not the primary factor we’re focused on.
Why is it important to consider such alternate treatment options?
Being on long-term blood thinners poses a risk. Although it’s a small risk, it’s fair to say that people don’t want to subject themselves to these risks or to complications from a medication if at all possible. Patients that detect an arrhythmia are at risk of stroke. This option can protect them from a stroke without increasing their bleeding risk.
Could a similar “as needed” approach be viable for other EP practices?
We just presented this abstract at Heart Rhythm 2016, so we haven’t heard if any other EP practices are doing something similar. Patients who have heard about our abstract through the media have contacted me with questions. However, this is not an official program that we are advertising to patients — we just wanted to offer patients options other than long-term anticoagulation.
Will further research be published soon in a manuscript?
Yes! I’m working with Dr. Marchlinski and 13 other physicians in our practice. Interest is growing a lot faster than we expected. We’re very motivated.