Last month, the Cardiovascular Roundtable had the opportunity to both attend and present at the 2017 Napa Atrial Fibrillation (AF) Symposium in Napa Valley, California. The symposium—hosted by the St. Helena Hospital Foundation in partnership with Gather Napa Valley and co-sponsored by the Heart Rhythm Society—was a three-day meeting of the minds of the country's leading experts in atrial fibrillation. Electrophysiologists, CV surgeons, cardiologists, primary care providers, AF care coordinators, and hospitals administrators spent the weekend learning and sharing best practices.
Here are our five biggest takeaways from the weekend.
1. The prevalence of AF in the United States is expected to increase dramatically.
The population of patients with AF in the United States is expected to grow to 12.1 million by 2030, with no signs of tapering off after that. This projected increase is turning the heads of CV programs across the country that have an opportunity to improve AF patient management.
US Prevalence Projections for Atrial Fibrillation
American Heart Association 2017, in Millions
Assumes no increase (blue dashed line) or logarithmic growth (grey dashed line) in incidence of AF from 2007.
2. The rising prevalence is due, in large part, to an increase in risk factors and lifestyle choices.
Research continues to show that lifestyle and behavior modification are central to the prevention and management of AF
Here are select risk factors and the associated evidence:
- Smoking. Current smokers have twice the risk of developing AF compared with non-smokers. But current smokers aren't the only ones who face an elevated CV risk: Former smokers have a 1.3x increased risk. Further, individuals who lived with a smoker during childhood or had a parent who smoked during gestational development face a increased AF risk as well.
- Sleep apnea. Sleep apnea is associated with a two- to threefold increased odds of developing AF.
- Diabetes. Diabetic patients have a 40% increased risk of developing AF compared to non-diabetic patients.
- Work/life balance. People working over 55 hours per week have a 1.4-fold increased risk of AF compared to those who worked standard hours.
- Body weight. A 10% reduction in body weight can reduce AF burden by six times.
3. Unlike other CV diseases, AF mortality has increased in recent decades.
A new article in JAMA analyzed the trends in CV mortality across the country from 1980-2014. Investigators discovered that while CV disease morality rates as a whole have declined since the 1980s, mortality rates due to AF have increased. Not only are the mortality rates different, but the areas of the country experiencing higher rates of AF mortality are largely clustered in the Northwest, while the areas of the country witnessing higher mortality rates from CV diseases overall are largely clustered in the Southeast.
While the investigators note that further research is necessary to better understand causes for regional variation, they propose that the factors behind the variation in mortality could include 1) variation in exposure to behavioral and environmental risks; 2) variation in treatment and interventions to minimize risk due to those exposures; and 3) quality of care delivery through emergency services and acute medical care.
[Access the JAMA article's U.S. maps with CV mortality rates here]
4. Optimal treatment is dependent on patient and disease progression.
Treatment for AF patients has expanded to include more choices for medical management (e.g., novel oral anticoagulants) and procedural management (e.g., cryoballoon ablation, surgical ablation). Patients with paroxysmal, standalone AF are typically recommended treatment with oral anticoagulants or catheter ablation. Where treatment options get more challenging is for 1) concomitant patients (i.e., patient has AF and valve disease) and 2) persistent AF patients (i.e., patient has chronic, longstanding AF).
Newer treatment options target these persistent, concomitant patients. Patients with AF requiring a coronary artery bypass graft surgery could be dually treated by the CV surgeon during the same procedure by performing a surgical ablation during the procedure. Patients with chronic, persistent AF for whom catheter ablation has failed in the past could be appropriate candidates for the newer hybrid ablation technique—where a CV surgeon performs a minimally invasive surgical ablation and then an electrophysiologist (EP) performs a catheter ablation either the same-day or several weeks after (staged).
Optimal technique as it relates to timing (i.e., same-day versus staged) was up for debate over the weekend. Physicians with experience on either side proved both could be successful. Our recent Cardiovascular Roundtable arrhythmia survey results revealed that while Roundtable programs performing hybrid ablations are fairly evenly split on performance method, a slight majority of programs perform the procedures staged over a several week period.
5. A multidisciplinary, comprehensive approach to patient treatment is key to success.
Atrial fibrillation is a chronic, complex condition to manage. Many of these patients are comorbid with other CV diseases, making optimal patient management more difficult. In fact, 57% of heart failure patients have AF and 37% of AF patients have heart failure.
An AF care team designed to provide comprehensive care includes those you would expect—like general cardiologists and electrophysiologists—as well as those you might overlook—like nutritionists, pulmonologists, CV surgeons, and care coordinators. To treat the growing and increasingly complex population of AF patients, CV programs must design care pathways and treatment plans that include multidisciplinary input and support—within and outside of the CV service line.
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Learn 6 steps to optimize CV organizational and leadership structures
CV programs have been developing cardiovascular service lines for years, but there’s no standard definition of what a service line entails. We define it as having a dedicated administrative body, a discrete budget, and a unified strategic plan.
When it comes to CV service line organizational and leadership models, there is no "right answer" for all programs. And there is typically no end state—it is usually a work in progress. These six steps and associated tools will assist you in defining the org chart and governance structure that’s right for you.