Feature Interview

The Atrial Fibrillation Center of Excellence: A Multidisciplinary Approach to Atrial Fibrillation

Erin D. Sharpe, ARNP; W. Michael Kutayli, MD, FACC; Matthew J. Kapalis, DO, FHRS; Robert L. Percell, Jr., MD, FACC, FHRS

Bryan Atrial Fibrillation Center of Excellence

Lincoln, Nebraska

Erin D. Sharpe, ARNP; W. Michael Kutayli, MD, FACC; Matthew J. Kapalis, DO, FHRS; Robert L. Percell, Jr., MD, FACC, FHRS

Bryan Atrial Fibrillation Center of Excellence

Lincoln, Nebraska

The Bryan Heart Atrial Fibrillation Center of Excellence (BRACE) Clinic was established 10 years ago to develop high-quality care for atrial fibrillation (AF) patients. Studies have demonstrated that a multidisciplinary approach to AF may improve outcomes.1

Atrial fibrillation is the most common rhythm disorder and it is ubiquitous on the global landscape.2 Stroke is the most dangerous result of AF and is increased 5-fold in AF patients.3 The number of hospitalizations from AF has increased by 60% over the last 20 years, primarily due to an earlier diagnosis, an aging population, and the increasing number of patients with heart disease.4 Risk factor modification for AF patients is exceedingly imperative yet inherently difficult and requires a multimodality approach.

Strict adherence to evidence-based guidelines is challenging in the management of AF and is associated with decreased morbidity and mortality.5 Recently, a simple “ABC” approach has been demonstrated to be efficacious in AF treatment: (A) Avoid stroke (with anticoagulants); (B) Better symptom management, with patient-centered decisions on rate or rhythm control; and (C) Cardiovascular and comorbidity risk optimization.6 Reports in the literature indicate that integrated specialty clinics may have a significant positive impact on patient outcomes, reduce repeat hospitalizations for AF, and improve mortality.7,8 Similar to published reports in the literature on other chronic cardiovascular conditions such as congestive heart failure (CHF) and acute coronary syndromes, coordinated care in AF has only recently become widespread.9 In a large meta-analysis, AF patients who were seen in integrated care clinics were noted to have significant mortality benefits, with a number needed to treat (NNT) of 19.9

The BRACE Clinic serves as the base of operations for the entire EP department. There are 11 staff members (including 3 physicians and 1 nurse practitioner) in the BRACE Clinic, 7 staff members in the Arrhythmia Clinic, and 8 staff members in the EP lab. A close relationship between the BRACE Clinic, Arrhythmia Clinic, AF Screening Clinic, research department, and the EP lab is crucial to specialized patient care, throughput, and follow-up.

The primary goal of the BRACE Clinic is to educate patients on their treatment options and deliver the highest quality of care. EP procedures are arguably the most complex procedures in all of cardiology, although our structural colleagues may choose to disagree. Treatment options may include anticoagulation therapy, dietary instructions, rate versus rhythm control strategies, intervention options, dose titration, AF-associated risk factor modification, and management or prevention of common adverse drug effects. Thorough education of patients with proper referrals, including all the risks and benefits, is essential to improving outcomes. All patients undergoing ablation or left atrial appendage closure are given literature with easy-to-follow pictures and diagrams as well as the opportunity to view educational videos to further enhance their knowledge. All the major device / arrhythmia manufacturers have informational handouts that are readily available. Additionally, all the EPs have pre-recorded talks that play on loop on our in-office television monitor, and we also all give community talks about AF on a regular basis.

AF patients are often referred for sleep studies or weight loss therapies combined with increased physical activity and exercise programs. Patients with diabetes, hypertension, and vascular disease are managed concomitantly with the Bryan Heart Cardiometabolic Clinic. Patients with heart failure are also seen in the Bryan Heart Improvement Program (BHIP) whether they have systolic dysfunction, diastolic dysfunction, or a combination of both. Pacemaker and ICD patients are followed in the Arrhythmia Clinic. These treatment modalities are commonly carried out in coordination with primary physicians, pharmacists, specialty clinics, and physicians, including endocrinologists and pulmonologists.

The BRACE Clinic has evolved to encompass management of all arrhythmias (not just atrial fibrillation), including atrial tachycardia, SVT, atrial flutter, ventricular tachycardia, and bradyarrhythmias. The BRACE Clinic also coordinates care for patients that require devices such as implantable loop recorders, pacemakers, leadless devices, ICDs, as well as CRT devices. Additionally, lead extractions and WATCHMAN (Boston Scientific) implants are handled through the BRACE Clinic. Scheduling procedures may involve multiple specialties such as non-invasive cardiology (TEE), anesthesiology, and cardiothoracic surgery as well as the appropriate device vendors.

The BRACE Clinic serves Lincoln, all of western Nebraska, eastern Colorado, northern Kansas, and southern South Dakota. Patients frequently travel >3-4 hours to receive procedures, and this travel is coordinated through BRACE.

On average, 75-100 patients are seen weekly in the BRACE Clinic. All new patients with arrhythmia issues referred from primary care, the emergency department, or cardiology are regularly able to be seen the following day as BRACE operates 5 days per week. Antiarrhythmic drug (AAD) therapy patients have specific protocols for monitoring electrolytes, thyroid and renal function, ECG QT findings, pulmonary function, and interval stress testing. These patients are then automatically referred if needed to endocrinologists, nephrologists, and/or pulmonologists. Prior to being hospitalized for AAD therapy initiation (dofetilide and sotalol), patients must have a pre-hospital pharmacist consult. Finally, obese patients are routinely counseled and referred to dieticians and exercise physiologists prior to invasive therapy. We are currently in the process of both expanding current protocols to make this an even more efficient process as well as adding additional physicians and nurse practitioners.

In the Arrhythmia Clinic, over 5000 devices are currently being followed remotely. Abnormalities noted on device interrogations are placed into a “low”, “medium”, or “high” priority status. Findings are relayed to nurses and then to physicians via Epic. These patients are contacted the same day and then “fast tracked” for appointments either at BRACE or with out-of-state cardiologists, and sometimes video visits usually within 48 hours. Physicians, nurses, nurse practitioners, schedulers, and technicians all participate in this coordinated process.

In the EP lab, 15-25 AF ablations are performed weekly with 10-15 device implants and 3-5 WATCHMAN implants. The EP lab was recently accredited by the American College of Cardiology.

In summary, the global burden of AF continues to grow at a rapid rate requiring a collective, integrated, multidisciplinary, and multimodal approach to patient care. The BRACE Clinic serves as the centerpiece in the diagnosis and treatment of AF patients in our region. 

Disclosures: The authors have no conflicts of interest to report regarding the content herein.

References
  1. Tran HN, Tafreshi J, Hernandez EA, Pai SM, Torres VI, Pai RG. A multidisciplinary atrial fibrillation clinic. Curr Cardiol Rev. 2013;9(1):55-62.
  2. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke. 1991;22:983-988.
  3. Go AS, Hylek EM, Phillips KA, et al. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA. 2001;285(18):2370-2375.
  4. Friberg J, Buch P, Scharling H, et al. Rising rates of hospital admissions for atrial fibrillation. Epidemiology. 2003;14(6):666-672.
  5. Hendriks JM, de Wit R, Vrijhoef HJ, Tieleman RG, Crijns HJ. An integrated chronic care program for patients with atrial fibrillation: study protocol and methodology for an ongoing prospective randomised controlled trial. Int J Nurs Stud. 2010;47(10):1310-1316.
  6. Lip GYH. The ABC pathway: an integrated approach to improve AF management. Nat Rev Cardiol. 2017;14(11):627-628.
  7. Frydensberg VS, Brandes A. Does an interdisciplinary outpatient atrial fibrillation (AF) clinic affect the number of acute AF admissions? A retrospective cohort study. J Clin Nurs. 2018;27(13-14):2684-2690.
  8. Yang PS, Sung JH, Jang E, et al. Application of the simple atrial fibrillation better care pathway for integrated care management in frail patients with atrial fibrillation: a nationwide cohort study. J Arrhythm. 2020;36(4):668-677.
  9. Gallagher C, Elliott AD, Wong CX, et al. Integrated care in atrial fibrillation: a systematic review and meta-analysis. Heart. 2017;103(24):1947-1953.
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