Role of nurses in the management of AF

MAASTRICHT, THE NETHERLANDS. Atrial fibrillation (F) particularly when combined with comorbid conditions such as hypertension, heart failure, diabetes and previous stroke/TIA is a complex condition. AF is now epidemic and is becoming an extremely costly public health problem. A team of Dutch cardiologists now report that care and follow-up provided by nurses are superior to the usual care provided by cardiologists when it comes to preventing AF-associated hospitalization and death.

Their study involved 712 AF patients (average age of 67 years, 59% male) who were randomly assigned to nurse-led care or usual care. The majority (55%) of the study participants had paroxysmal AF, while the remaining had either persistent (16%) or permanent (29%) AF. In 83% of cases AF episodes were symptomatic. The patients were by no means lone afibbers with 53% having hypertension, 13% having experienced a prior stroke or TIA, 17% having coronary artery disease or heart failure, and 14% having diabetes. About half the patients (49%) had been prescribed a beta-blocker, while 14% were on digoxin. Most study participants (72%) had one or more risk factors for ischemic stroke and 89% were prescribed warfarin (57%) or aspirin (32%).

At the start of the study all patients underwent laboratory testing, electrocardiography, Holter monitoring, and echocardiography. Members of the usual care group then saw a cardiologist for a 20-minute consultation during which their test results were discussed and medication prescribed as deemed necessary by the cardiologist. Ten-minute follow-up visits were scheduled for every 6 months thereafter for at least a year.

The first visit for patients in the nurse-led group was scheduled to last 30 minutes. During it, the nurse specialist took the patient’s history and informed them about the general nature of AF, its symptoms and possible complications, the results of the diagnostic tests, and discussed applicable treatment options. The patient’s data was then entered into the CardioConsult AF computer program. The program calculates a patient profile based on symptoms, type of AF and stroke risk (CHADS2 score), and then proposes the most appropriate approach to managing the condition in accordance with the 2006 American and European guidelines for the management of atrial fibrillation. The nurse specialist discussed the protocol with the cardiologist before implementation. Half-hour follow-up visits were scheduled for every 6 months thereafter for at least a year.

During follow-up 48 patients (13.5%) in the nurse-led group were hospitalized for AF-related problems as compared to 74 patients (20.8%) in the group receiving usual care by a cardiologist. Four patients (1.1%) in the nurse-led group died from cardiovascular causes as compared to 14 patients (3.9%) in the usual care group. The incidence of stroke was 0.8% in the nurse-led group and 1.4% in the usual care group – far lower than the 5%/year risk often quoted for AF patients.

The authors of the study conclude “that like in the aviation industry, modern medicine benefits from protocolized procedures and the presence of a co-pilot (nurse specialist), thereby preventing medical accidents.”
Hendriks, JML, et al. Nurse-led care vs. usual care for patients with atrial fibrillation. European Heart Journal, March 27, 2012 [Epub ahead of print]