Dhiraj Gupta, consultant cardiologist and electrophysiologist at Liverpool Heart and Chest Hospital, (Liverpool, UK) discusses the current burden of atrial fibrillation (AF) on healthcare services, current treatment strategies, and the prospects for arrhythmia treatment post-COVID-19.
What is the current burden of AF on health services, and what are the costs associated with it?
The number of AF patients is at a record high, with approximately 11 million patients in Europe today. Depending upon what and how one measures, the European health systems spend between €660‒€3,286 million annually on AF care costs. Many AF patients seek medical care, often repeatedly, to find relief from symptoms. Sadly, AF-related stroke continues to affect many people in spite of increasing uptake of newer oral anticoagulants. In the UK alone, over 16,000 strokes occurred in 2019 in patients with known AF.
What complications can arise from AF?
We know that if left untreated, AF patients have a significantly increased risk of stroke and heart failure, five times and 2.5 times respectively. In addition, an association between AF and dementia is also being increasingly recognised. Many patients also develop bleeding complications from the oral anticoagulants they need to prevent stroke.
What are the current treatment options?
Treatments aimed to reduce the risk of stroke are paramount. In addition, many patients experience a range of symptoms from AF including fatigue, dizziness, anxiety and shortness of breath, with up to half of all patients reporting a significant reduction in their quality of life. For these patients, rhythm control is advised; this can be attempted in a variety of ways, including with anti-arrhythmic drugs (AADs), or with catheter ablation.
How can treating AF earlier reduce the burden on health systems? What data exist to support this?
Prompt diagnosis of AF is vital as a patient’s risk of having a life-threatening event including stroke, heart failure, and death increases overtime. Each year, as many as 20% of patients with paroxysmal AF will progress to a more severe disease state, persistent AF, which we know often results in complications such as new onset or worsening heart failure. Recent data presented at ESC showed catheter ablation is up to 10 times more effective than AADs at delaying progression to persistent AF.1 It has been well established that ablation markedly reduces unplanned hospitalisations—and associated costs—and many studies have even shown reduced rates of strokes in patients who undergo catheter ablation. Amongst patients undergoing catheter ablation, time from AF diagnosis to ablation is a strong determinant of procedural success. This underscores the need to establish efficient patient referral pathways so that suitable patients can access modern treatments as early as possible.
How can one improve the success rates of catheter ablation for AF?
This can be achieved in several ways. First and foremost is patient selection. As I mentioned earlier, early treatment supports superior outcomes. In addition, comorbidities and the extent to which the disease has negatively impacted the patient’s quality of life may also be taken into consideration. Secondly, ablation outcomes have been strongly linked to procedural volumes and so hospitals and individual physicians should strive for as high volumes as possible. Thirdly, physicians should be aware that there might be differences in ablation technology. Earlier this year, we published two studies comparing the latest Radiofrequency (RF) technologies to the latest Cryoballoon technologies. One published in the Advances in Therapy journal was a matching adjusted indirect comparison that showed a reduction of 70% in atrial arrhythmia recurrence using CARTO based RF ablation using the current technology of automated lesion tagging (CARTO VISITAG) with Ablation Index/SURPOINT. Our second study, a network meta-analysis comparing five different catheter ablation devices across twelve studies, published in the Journal of Comparative Effectiveness and Research, provided data showing that the same CARTO RF based technology delivered the highest 12-month freedom from arrhythmia for paroxysmal AF patients.
How can this evidence impact AF management and related burden for Health care systems?
It is critical that physicians strive for the highest possible success rates without compromising on safety. Some physicians may prefer a procedure with a 60% success rate to one with 80% single procedure success if the former means a shorter and less ‘complex’ procedure. However, if one offers the same choice to patients, most would prefer the latter as that means half the failure rate (20% rather than 40%). For a procedure that is still largely performed for improving patient’s symptoms and quality of life, this patients’ perspective needs to be taken into consideration. Furthermore, higher procedure success rates will inevitably be associated with lower recurring burden on health care systems.
How can healthcare be adapted going forward to provide for the needs of this group of patients?
I feel that the best outcomes can be achieved with empowering patients through education. In addition, AF is best tackled by a multi-disciplinary approach that involves nurses, GPs and specialists working together to support optimal management, including work around earlier detection and prompt treatment to help prevent disease progression. There is increasing appreciation that AF burden can be reduced, and ablation outcomes can be improved by effective management of associated risk factors such as hypertension, obesity and alcohol excess. This ‘Risk Factor Management’ approach should form an integral part of AF management.
What should AF care look like post-COVID-19?
We have already begun to see changes to our practice as a result of COVID-19, with an increase in remote monitoring and digital appointments. Alongside this, I think we will continue to see the adoption of digital and remote monitoring, such as remote ECGs and mobile apps, which can deliver real benefits to hospitals and patients.
- ATTEST ESC 2019