Atrial fibrillation (AF) is the most common arrhythmia seen in clinical practice.
The symptoms often associated with AF, such as dyspnea, fatigue, and palpitations,
may be associated with other cardiac conditions such as heart failure, which may make
recognition of the condition in certain patients more difficult. This can, in turn,
cause a delay in the performance of a timely evaluation and treatment initiation.
There are multiple identifiable risk factors for AF including hypertension, obesity,
smoking, diabetes, sleep apnea, and alcohol intake. An enduring question is how and
when is it best to address these risk factors. To date, there is a scarcity of evidence-based
studies demonstrating preventive interventions that reduce or prevent the occurrence
of AF.
Today, rhythm control strategies for AF are limited in efficacy. Antiarrhythmic drug
(AAD) therapy pros and cons have been well-established. The efficacy of AADs is at
best 52%, based on a meta-analysis of 32 studies.
1
Electrical cardioversion has a documented 40% to 60% recurrent AF rate within three
months and up to a 60% to 80% recurrence rate within one year.
2
Catheter ablation has a single-procedure success rate of 50% to 64%, which increases
to 65% to 77% with repeat ablations and with the patient off AADs.
1
Given the limitations of current therapy, interventions that increase the efficacy
of treatment are of obvious importance.
Several studies have shown that aggressive risk factor reduction improves the long-term
outcomes of catheter ablation. The Aggressive Risk Factor Reduction Study for AF and
Implications for the Outcome of Ablation (ARREST-AF) cohort study found that a structured
physician-directed risk factor and weight management program results in the significant
improvement of long-term outcomes, including specifically significant improvement
in left atrial volumes and left ventricular hypertrophy, leading to a lower risk of
AF. Risk factor management included the control of blood pressure, weight, lipid levels,
sleep-disordered breathing, and glycemic levels in addition to catheter ablation.
3
The Long-term Effect of Goal-directed Weight Management in an AF Cohort (LEGACY) study
separately showed that AF burden, reductions in symptom severity, and long-term freedom
from AF were dose-dependent on the amount of weight lost.
4
Another trial, the Cost-effectiveness and Clinical Effectiveness of Risk Factor Management
Clinic in AF (CENT Study), revealed that a structured physician-directed aggressive
risk factor modification program was clinically effective and cost-effective in the
management of AF. The risk factor management strategy was associated with higher upfront
costs due to increased clinic visits, but, in the long term, it reduced overall costs
by decreasing the number of ablations needed.
5
These trials indicate that risk factor reduction or control lowers AF and costs. However,
most relevant studies to date have been physician-directed and resource-intensive.
Given a relative physician shortage, alternate ways of delivering care should be explored.
One of the few nonphysician studies from the University of Pennsylvania developed
a program addressing obesity and obstructive sleep apnea (OSA) in AF patients in their
electrophysiology outpatient clinics. This nurse-led program achieved greater success
rates in the included patients with regard to weight reduction and OSA diagnosis and
treatment.
6
It has been previously demonstrated that involving nurses in heart failure programs
as well as hospital education programs decreases patient readmission rates and costs
and improves the quality of life of patients.
7
The pilot trial by Hickey et al.
8
is timely in that it addresses a multitude of issues related to patient education
and compliance with recommended treatments of AF. Nurses are effective at educating
patients and following up with those with chronic conditions, as evidenced in heart
failure and inflammatory bowel disease populations. Nurses have been documented to
promote decreased visits through education and alternate forms of communication.
7,9
For certain medical conditions, patients felt that telemedicine was a convenient alternative
to traditional in-office care without compromising the quality of care.
9
This study had participants utilizing the Life’s Simple 7® assessment for the identification
of goals for lifestyle and self-care management behaviors and the My AFib Symptom
Tracker to monitor their symptom details, both from the American Heart Association
(Dallas, TX, USA). Participants selected lifestyle modification areas from the Life’s
Simple 7® interface that they believed they could act upon over the study period.
For six months, the participants participated in biweekly video chats with a cardiac
nurse via the portal, representing the behavioral intervention of motivational interviewing.
The cardiac nurse reviewed and discussed lifestyle modifications and self-management
strategies incorporated by the participant since the previous session. The sessions
were guided by individual cardiac goals and the patient’s progress. Participants documented
events of note on the My AFib Experience Symptom Tracker and identified whether symptoms
occurred at rest or during exercise as well as the severity and frequency of the occurrences.
This helped to guide patients to better recognize the association of symptoms and
triggers with AF rather than other cardiac conditions.
The results of the 53 study participants demonstrated that 98% liked having a dedicated
nurse working with them on a biweekly basis to improve their cardiac health and AF
recognition. Some participants reported a desire to have more frequent contact with
the nurse, while 86% of participants chose increasing physical activity as the primary
goal they could improve upon and 65% decided to include improving their diet in their
goals. On average, there was a 3-lb decrease in weight and a 5-mmHg decrease in systolic
blood pressure from baseline. The overall reported compliance rate was 65% for the
entire cohort. Participants who received the intervention achieved a mean one-point
improvement in their Life’s Simple 7® score over the intervention period, while 70%
of participants improved their Life’s Simple 7® score by two or more points from baseline
to six months. Further, 81% of participants reported that the intervention enhanced
accessibility, eliminated extra in-person visits, provided health information for
achieving “my health goals,” and felt the digital sessions to be as good as in-person
meetings with the nurse practitioner (NP). They reported the “human connection” provided
by the nurse combined with the motivational interviewing to be the most essential
elements in helping them stay on course with sustaining a healthy lifestyle and with
overall AF management.
This trial successfully demonstrated the efficacy of NPs regarding communicating and
following patients through a digital portal and helping them to stay motivated and
focused. In addition, providing education to and tracking study participants, especially
those with loop recorders, led patients to better be able to identify and distinguish
their AF symptoms and associated triggers. The authors also found that regular contact
between patients and the cardiology NP helped with medication compliance and using
proper medication strategies, especially in terms of antiarrhythmics and anticoagulation
agents.
One limitation of the study is its small sample size of 53 individuals. It was also
a single-arm study without a control arm and was conducted at a single center, all
of which were identified by the authors as limitations. The results could be attributed
to a placebo effect or treatment bias, including the mere attention given to participants.
10
Another limitation to this study is that it did not address some major modifiable
risk factors such as sleep apnea and alcohol consumption, both of which have been
documented to contribute to and impact AF burden. Also, this study was only six months
long and so the longer-term outcomes remain to be seen.
That being said, this study is timely as health care providers continue to look for
alternate ways of providing care and due to its preventive focus. Given the limitations
of our current treatment strategies for AF, lifestyle modification to increase overall
treatment success is both plausible and feasible. Also, given the ongoing physician
shortage and unique skillsets that nurses can provide, the focus on nurse-driven lifestyle
modification interventions is not just optimistic but necessary. We eagerly look forward
to the next phase of this study.