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Specialized Atrial Fibrillation Clinic reduces cardiovascular morbidity and mortality in patients with atrial fibrillat

Specialized Atrial Fibrillation Clinic reduces cardiovascular morbidity and mortality in patients with atrial fibrillation. Jeroen ML Hendriks, MSc Robert G Tieleman, PhD, MD Department of Cardiology Cardiovascular Research Institute Maastricht University Medical Centre, The Netherlands

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Specialized Atrial Fibrillation Clinic reduces cardiovascular morbidity and mortality in patients with atrial fibrillat

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  1. Specialized Atrial Fibrillation Clinic reduces cardiovascular morbidity and mortality in patients with atrial fibrillation Jeroen ML Hendriks, MSc Robert G Tieleman, PhD, MD Department of Cardiology Cardiovascular Research Institute Maastricht University Medical Centre, The Netherlands Martini Hospital Groningen, The Netherlands

  2. Euro Heart SurveyAntithrombotics according to CHADS2 score • Poor adherence to guidelines on management of AF • Non-adherence to guidelines increased morbidity / mortality Nieuwlaat et al. EHJ 2005, 2006

  3. Multivariate analysisantithrombotic guideline deviance Nieuwlaat et al. Am Heart J 2007

  4. Substitution of care by specialized nurses Management of AF according to guidelines Dedicated knowledge software Supervision by cardiologists The AF-Clinic An integrated chronic care program for patients with atrial fibrillation

  5. Hypothesis Nurse-led, guideline based, software-supported AF-Clinic, supervised by cardiologists improves clinical outcome in patients with atrial fibrillation in comparison to usual care

  6. Methods • PROBE: Prospective, Randomized, Open label, Blinded Endpoint trial, comparing the AF-Clinic to usual care • Randomization of 712 pts with newly diagnosed AF into Nurse-led Care group or Usual Care group • Inclusion criteria • Age ≥ 18 years • AF documented on ECG • Exclusion criteria • Unsatisfactorily treated co-morbidity (hypertension, heart failure, …) • Follow-up at least 1 year

  7. Primary endpoint (composite) • Cardiovascular mortality • Cardiovascular hospitalization for • Heart failure • Stroke • Acute myocardial infarction • Systemic embolism • Bleeding • Arrhythmic events • Atrial Fibrillation • Syncope • Sustained ventricular tachycardia • Cardiac arrest • Life-threatening effects of drugs

  8. Baseline characteristics

  9. Baseline characteristics

  10. Results After a mean follow-up of 22 months • Composite end point - 51 patients (14.3%) Nurse-led Care - 74 patients (20.8%) Usual Care (HR 0.65, 95% CI 0.45-0.93)

  11. Results: composite endpoint

  12. Results • Cardiovascular hospitalization - 48 patients (13.5%) Nurse-led Care - 68 patients (19.1%) Usual Care (HR 0.66, 95% CI 0.46-0.96)

  13. Causes of cardiovascular hospitalization

  14. Results • Cardiovascular death - 4 patients (1.1%) Nurse-led Care - 14 patients (3.9%) Usual Care (HR 0.28, 95% CI 0.09-0.85)

  15. Causes of cardiovascular death

  16. Results: guideline adherence • Echocardiogram performed • Laboratory assessment of Thyroid Stimulating Hormone • Application of appropriate anti-thrombotic treatment • Appropriate prescription of Vaughan-Williams class I or III • Avoiding rhythm control strategy in asymptomatic patients • Avoiding rhythm control drugs in patients with permanent AF

  17. Results: guideline adherence • Echocardiogram performed • Laboratory assessment of Thyroid Stimulating Hormone • Application of appropriate anti-thrombotic treatment • Appropriate prescription of Vaughan-Williams class I or III • Avoiding rhythm control strategy in asymptomatic patients • Avoiding rhythm control drugs in patients with permanent AF

  18. Conclusion Management of atrial fibrillation patients in a specializedAF-Clinic improves outcome compared to usual care.

  19. Writing Committee HJGM Crijns JML Hendriks RG Tieleman HJM Vrijhoef R de Wit MH Prins R Pisters LAFG Pison Y Blaauw Steering Committee HJGM Crijns RG Tieleman R de Wit HJM Vrijhoef Adjudication Committee C Franke H ten Cate GVA van Ommen RJMW Rennenberg Members of the study group

  20. Back-up slides

  21. Discussion Difficult to pinpoint nurses or guidelines or dedicated software as the sole reason for results Improved guideline adherence and outcomes due to an integrated approach: a combination of ingredients

  22. Results: multivariate analyses

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