Atrial fibrillation (AF) is the most common cardiac arrhythmia, impacting over 33 million people worldwide.1 According to the Centers for Disease Control, an estimated 2.7 to 6.1 million people are affected by this condition in the U.S. Furthermore, these large numbers may underestimate the prevalence of AF, since many patients are asymptomatic and therefore have not yet been diagnosed. Atrial fibrillation can have devastating effects on morbidity and mortality. It has been identified to be the cause of more than 750,000 hospitalizations annually and contributes to an estimated 130,000 deaths each year.2 With the anticipated growth in the aging population worldwide, especially in developed countries, it is anticipated that the prevalence of AF will continue to grow incrementally and may even reach epidemic proportions. For these reasons, it is imperative that this condition be recognized early so it can be treated effectively.
Treatment strategies for AF include anticoagulation, heart rate control, and maintenance of sinus rhythm by antiarrhythmic medication management and/or catheter ablation. Among these treatment strategies, catheter ablation is considered one of the most effective for long-term maintenance of sinus rhythm.3 In the past, catheter ablation was usually offered to patients with symptomatic paroxysmal AF that had failed antiarrhythmic drug therapy. However, it can now be offered as first-line therapy in these patients and is being increasingly used in patients with persistent and long-standing persistent AF.
Our current approach to catheter ablation at the Hospital of the University of Pennsylvania (HUP) has been previously described4 and is typically limited to pulmonary vein isolation along with targeting of non-pulmonary vein triggers, which are identified by standardized stimulation protocol. Post-ablation clinic visits occur around 6 weeks, 6 months, and 1 year, after which yearly visits are advised. Our routine practice involves a 30-day transtelephonic monitor at discharge, 6 months, and 1 year, as well as if patients report symptoms suggestive of arrhythmia recurrence.5 In the absence of arrhythmia recurrence, antiarrhythmic drugs are discontinued 6 weeks post ablation for paroxysmal AF patients, and 3-6 months’ post-ablation for non-paroxysmal AF patients. Using this approach over the past nearly 2 decades, we have achieved single-procedure success rates of ~70% in patients with paroxysmal AF, and these rates are lower in patients with persistent and/or long-standing persistent AF.6 Similar outcome data for AF ablation have been consistent between centers.6
AF patients that fail catheter ablation share certain traits, including obesity, poorly treated obstructive sleep apnea (OSA), and/or uncontrolled hypertension. Thus, treating these risk factors may potentially improve the outcomes of catheter ablation. Recent studies have demonstrated the positive impact of risk factor modification (RFM) in atrial fibrillation patients. For example, in the ARREST-AF trial, the investigators evaluated risk factors such obesity, as hypertension, glucose intolerance/diabetes mellitus, hyperlipidemia, untreated OSA, smoking, and alcohol excess, and demonstrated that RFM significantly improved the long-term outcomes of AF ablation by reducing AF burden and severity.7 Although this physician-led program demonstrated positive results, it was a highly resource-intensive approach to RFM, and may not be easily replicated globally across different health systems.
With that in mind, we developed a clinical initiative at HUP called Penn AF Care, the goal of which is to target the two most common risk factors that are found in the U.S. AF population: obesity and OSA. This program is managed by a registered nurse who works under the close supervision of an electrophysiologist.
Our approach included screening new AF patients prior to their clinical visit using the following eligibility criteria: 1) body mass index (BMI) >30 for identifying obese patients, and 2) untreated OSA or patients at high risk for OSA (according to the Berlin questionnaire). AF patients who were already being seen in our clinical practices were also referred to the program if they were deemed as good candidates by their EP providers. Eligible patients were offered participation in the RFM program, but enrollment and ongoing active involvement was voluntary.
Our approach to obesity management included patient education, individualized lifestyle modification counseling, and collaboration with patients to develop specific dietary and exercise goals based on their typical daily diet and physical activity. Healthy eating behaviors were encouraged, such as increasing fruit and vegetable intake, focusing on portion control, and reducing the intake of processed foods and added sugars. Attention to the reduction of alcohol was also emphasized. Patients were also encouraged to document in a food journal (including food intake as well as alcohol and smoking habits). ChooseMyPlate recommendations from the Department of Agriculture were utilized as reference material for patients and their families, and patients were educated on how to read nutritional labels.8 After the initial meeting and educational session was completed, longitudinal care management via telephone encounters enabled the RN to continue to provide support, accountability, and ongoing RFM counseling.
Our early experience has shown that patients enrolled in the RFM program achieved greater weight loss than those who declined participation. Patients who achieved weight loss demonstrated significant improvement in their quality of life and arrhythmia symptoms from baseline to 6 months.9 (Figure 1)
Our approach to OSA management included patient education regarding the relationship between OSA and AF, as well as interdisciplinary coordination and referral to the Penn Sleep Center. Pertinent questions were asked to rapidly screen and evaluate for potential OSA. Patients underwent home or in-lab sleep studies, and if determined to have OSA, were referred for treatment. In addition, if CPAP chip data revealed poor compliance, patients were sent to the Penn Sleep Center to identify and target treatment barriers. Even if patients reported poor tolerance to CPAP in the past, they were encouraged to pursue treatment again because of ongoing improvements in CPAP technology. Our Penn AF Care experience analyzed the OSA population referral and sleep study completion rates in the 1 year preceding (November 1, 2015 to October 31, 2016) compared to 1 year following (November 1, 2016 to October 31, 2017) initiation of Penn AF Care. It demonstrated a substantial increase in referrals of patients identified as high risk for OSA (n=60 versus n=93; P<0.05), as well as improvement in sleep study/referral completion rates (38% versus 86%; P<0.05).9 (Figure 2)
Our approach has demonstrated that identification and treatment of risk factors can improve quality of life and potentially reduce the burden of AF symptomatology. Our approach has also found that participation in a structured RFM program can have a positive impact on AF risk factor profile. Enrolled patients reported improvement in quality of life as well as their AF symptoms (Figure 3). The limitations identified in running such a program include sustainability of longitudinal care management, inherent difficulty of achieving weight loss in a voluntary program, patient attrition, and maintaining long-term funding for an initiative which is not yet a billable/reimbursable service. In addition, the impact of this limited RFM strategy in improving catheter ablation outcomes remains to be seen. We are currently analyzing the follow-up data to determine this.
The Penn AF Care initiative utilizes a multidisciplinary strategy with a care team comprised of cardiac electrophysiology, pulmonary medicine, endocrinology, and nutrition services. Such collaborative effort can be easily fostered within many hospitals in the U.S. Thus, our model of limited RFM is potentially reproducible. We are encouraged by the preliminary data suggesting that the implementation of a RFM project offers benefits that may complement traditional AF management strategies. Identifying and addressing risk factors alongside treating atrial fibrillation with our standard catheter ablation strategy may be a positive contribution to improving AF ablation efficacy. By being educated early on in the AF disease process, patients are more likely to make positive changes in their lifestyle. Our hope is that RFM becomes an important part of comprehensive AF management, and we are encouraged by the latest updates of the AHA/ACC/HRS guidelines that now include obesity management as part of AF treatment. If the Penn AF Care initiative shows improvement in AF outcomes in patients, it may convince key stakeholders to support the program through more resources and manpower. Future programs of this nature could then be implemented into similar populations throughout the country.
Disclosure: Ms. Parham has no conflicts of interest to report regarding the content herein.
- Chugh SS, Havmoeller R, Narayanan K, et al. Worldwide epidemiology of atrial fibrillation: a global burden of disease 2010 study. Circulation. 2014;129:837-847.
- Atrial fibrillation Fact Sheet. Centers for Disease Control and Prevention (CDC) website. https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_atrial_fibrillation.htm Updated August 22, 2017. Accessed April 7, 2019.
- HRS/EHRA/ECAS/APHRS/SOLAECE (2017). Expert Consensus Statement, Heart Rhythm Society. https://www.hrsonline.org/Policy-Payment/Clinical-Guidelines-Documents/2017-HRS-EHRA-ECAS-APHRS-SOLAECE-Expert-Consensus-Statement-on-Catheter-and-Surgical-Ablation-of-Atrial-Fibrillation Accessed April 7, 2019.
- Dixit S, Marchlinski FE, Lin D, et al. Randomized ablation strategies for the treatment of persistent atrial fibrillation: RASTA study. Circ Arrhythm Electrophysiol. 2012;5:287-294.
- Kapa S, Epstein AE, Callans DJ, et al. Assessing arrhythmia burden after catheter ablation of atrial fibrillation using an implantable loop recorder: the ABACUS study. J Cardiovasc Electrophysiol. 2013;24(8):875-881.
- Dixit S, Lin D, Frankel D, Marchlinski FE. Is the elimination of triggers sufficient? Current controversies in catheter ablation of atrial fibrillation. Circ Arrhythm Electrophysiol. 2012; 5:1216-1223.
- Pathak RK, Middeldorp ME, Lau DH, et al. Aggressive risk factor reduction study for atrial fibrillation and implications for the outcome of ablation: the ARREST-AF cohort study. J Am Coll Cardiol. 2014; 64:2222-2231.
- ChooseMyPlate.gov. U.S. Department of Agriculture. https://www.choosemyplate.gov/. Accessed April 7, 2019.
- Yaeger A, Cash NR, Parham T, et al. A Nurse-Led Limited Risk Factor Modification Program to Address Obesity and Obstructive Sleep Apnea in Atrial Fibrillation Patients. J Am Heart Assoc. 2018;7(23):e010414.
- January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. J Am Coll Cardiol. 2019; DOI: 10.1016/j.jacc.2019.01.011.