Perception and Reality: The Opportunity of AFib

For years I have been fascinated by the peculiar relationship between the perception of a situation and its reality.

My earliest recollection of such consternation was as a little leaguer trying to fathom the mysterious alchemy by which our manager divined that the .390 hitter batted fifth and the .412 hitter third, both obviously failing to get a hit six out of ten times at bat. Nonetheless, the superior batting average afforded its owner great status in our minds and in our club house, a situation ingeminate on every team in the league. Continue reading

Anticoagulation Consortium Roundtable Tackles Gaps in Care

This post was authored by Richard J. Kovacs, MD, FACC, chair of the ACC Anticoagulation Initiative Work Group

In recent years, we have seen many new oral anticoagulants enter the marketplace, and Anticoagulation Roundtablewith the options come many new questions. Anticoagulation therapy is unique in that it crosses over many medical specialty areas, including cardiology, primary care and internal medicine, emergency physicians, hematologists, neurologists, surgeons, electrophysiologists, clinical pharmacists and nurse practitioners. These professionals interact with patients and their caregivers, with the pharmacies dispensing drugs and information and with the health care systems paying the bills. Overseeing the safety of the drugs we use are regulatory agencies and drug surveillance systems. Needless to say, anticoagulation management is a complex topic that is surrounded by debate. Continue reading

ACC’s New Community Explores the Benefits and Limitations of Anticoagulants

This post was authored by Robert Giugliano, MD, SM, FACC, editor-in-chief of the Anticoagulation Management CardioSource Clinical Community.

Last year the ACC launched the Anticoagulation Initiative, a comprehensive quality effort to help facilitate a greater understanding of treatments and practice patterns in patients with atrial fibrillation, particularly given an increasing number of new anticoagulant treatment options entering the marketplace. The initiative is a multidisciplinary effort that addresses gaps in knowledge in order to improve the quality of care in patients with an indication for anticoagulation. Continue reading

Keeping Relevant in a Changing Field – the Expansion of the PINNACLE Registry

By William J. Oetgen, MD, MBA, FACC, senior vice president of Science and Quality of the ACC.

The ACC’s NCDR® is comprised of six hospital-based registries and one ambulatory registry, known as the PINNACLE Registry®. These registries measure the application of clinical guidelines in the real world setting – which helps us target national opportunities for quality improvement.

The PINNACLE Registry currently has 5.3 million patient encounter records covering 1.5 million unique patients, submitted from over 550 office locations nationwide. Of those patients, nearly 320,000 have atrial fibrillation (AFib), which is the most common arrhythmia in clinical practice, and is responsible for 15-20 percent of all strokes. Due to the growing need for the understanding of treatments and practice patterns for AFib, last year we announced the expansion of the PINNACLE Registry to include a new platform focusing on AFib, and include the next generation of anticoagulants coming online.

As new treatments are introduced to the market, assessing shifts in care patterns – and the impact of these shifts on patients – is a top clinical and research priority. The Registry can provide a means to monitor practice pattern changes over time while we rigorously assess current practice patterns and provide feedback reports to help providers evaluate and improve adherence to established guidelines and performance measures. We are also interested to see if these new medications coming online change the way doctors think about stroke prevention, which will ultimately help us close a long-standing quality gap in anticoagulation.

PINNACLE-AF is already yielding powerful clinical insights, and a study published last year in the American Journal of Cardiology used the PINNACLE Registry to look at treatment rates with warfarin in outpatients with nonvalvular AFib who were at moderate to high risk for stroke, as well as the extent of patient- and practice- level variation in warfarin use. The investigators found that warfarin treatment in AFib was suboptimal, with large variations in treatment observed across practice, and noted that their findings suggest important opportunities for practice-level improvement in stroke prevention for outpatients with AFib and define a benchmark treatment rate before the introduction of newer anticoagulant agents.

Because global anticoagulation patterns, especially in emerging markets, are less understood, the ACC recently conducted a transnational survey of AFib patterns the U.S., U.K., Germany, Brazil, India, and China, in order to develop a broader understanding of the causes of gaps in anticoagulation. The October issue of CardioSource WorldNews details the results, so be on the lookout for your copy hitting newsstands in the coming weeks. As mentioned in a previous blog post, the College is currently in the early stages of developing a comprehensive initiative to address gaps in treatment and encourage compliance with guideline-recommended care.

The power of registries is immense, and we encourage the use of this quality improvement tool – all in the name of improving quality and outcomes for patients. Expect to see more data and research come to fruition in the coming months, especially in the topics related to kidney function and bleeding risk and events which are areas of clinical import with the next generation of anticoagulants.

Treating Atrial Fibrillation: 5 Reasons to Choose Rhythm Control

This post is authored by Gregory F. Michaud, MD, FACC, and Roy M. John, MD, FACC.

Most patients with atrial fibrillation (AFib) are elderly and symptoms are effectively managed with medications that control the ventricular rate. Anticoagulation should be administered in patients who are at significant risk of stroke (CHADS-VASC ≥ 2-3). Rhythm control, however, may be preferable in some patients. Here are five reasons to choose rhythm control over rate control in treating patients with atrial fibrillation, regardless of whether AFib episodes are paroxysmal or persistent:

  1. Symptoms despite reasonable attempts at rate control. A word of caution when evaluating a patient for symptoms – patients with exertional dyspnea, poor exercise tolerance or fatigue may be incorrectly labeled “asymptomatic” in the absence of palpitations.
  2. Intolerance to effective rate control medications.
  3. Significant diastolic dysfunction. Often these patients do not tolerate AV dysynchrony even when the ventricular rate is well controlled. A classic example is a patient with hypertrophic cardiomyopathy.
  4. Tachycardia-related cardiomyopathy and poor response to AV nodal blocking agents.
  5. Young patients with persistent or frequent paroxysmal atrial fibrillation.

Don’t miss the free web-based symposium, Rhythm Control:  What Therapy for What Patient? on Thurs., Sept. 27 at 12:00 pm ET. Case examples to illustrate clinical decision pathways and the pros and cons of various therapeutic options will be presented. Visit the joint ACC/Heart Rhythm Society AFib CardioSource Clinical Community for more information.

This blog post is part of a series of blog posts during AFib Awareness Month. Visit ACC’s Facebook page for additional information. The joint ACC/HRS AFib CardioSource Clinical Community is an online community that addresses atrial fibrillation topics that are relevant to routine and advanced practice. The community offers a collaborative space that facilitates interaction between clinical disciplines by offering an article of the month series, videos, case challenges, hot topics and more.

Tools and Initiatives to Incorporate Best Practices in Day-to-Day Care

This post is authored by Richard Kovacs, MD, FACC, chair of the Best Practices and Quality Improvement Subcommittee, a subcommittee of the College’s Clinical Quality Committee.

The ACC is leveraging AFib Awareness month to highlight the many ways the College has stayed on top of the clinical and practice needs and demands of CV professionals in what is truly an evolving landscape.

This month the ACC launched an Atrial Fibrillation (AFib) Toolkit to provide tools and strategies for the patient care team to support high-quality care for patients with AFib.  Rather than only defining high-quality AFib care as defined by clinical performance on National Quality Forum endorsed measures, the AFib Toolkit establishes clear goals for overall high-quality AFib care by identifying and filling gaps in the knowledge and behavior of the patient and the patient care team in meeting these goals.

Included in the AFib Toolkit:

  • Five tools focused on diagnosis and risk assessment
  • Four tools, plus 23 individual drug monographs, for treatment and management of AFib
  • Three tools focused on patient education

As noted in last week’s blog post, AFib is the most common arrhythmia in clinical practice, and is responsible for 15-20 percent of all strokes, which account for 1 in 17 deaths in the U.S. and rank third among all causes of death after heart disease and cancer. In addition to improving clinician adherence to National Quality Forum endorsed performance measures for AFib, the AFib Toolkit will increase patient awareness of the risks associated with AFib, and enhance patient engagement in their AFib care plan.  Provider understanding and inclusion of patient behavior, choices, and lifestyles in care planning is especially important with AFib because of the rapidly evolving landscape of AFib therapies.  The AFib Toolkit is an opportunity to identify approaches for supporting the patient-provider partnership in meeting care goals among considerable safety and efficacy concerns.

In addition to the AFib toolkit, the ACC provides innovative educational programs like A New ERA v 2.0, a free Performance Improvement-Continuing Medical Education activity designed to help physicians improve the care of their patients with atrial fibrillation. To track data of patients with AFib, last year the PINNACLE Registry launched a new platform, PINNACLE-AF, focusing on atrial fibrillation and including the next generation of anticoagulants. Currently a new national anticoagulation initiative, led by ACC, is under development to drive awareness of the efficacy and safety of new anticoagulation therapies.

In the end, whether we’re talking about AFib, or another area identified as ripe for improvement, ACC members need real-time, easy-to-use solutions that cross the spectrum of quality, advocacy and education and bring about real change. The efforts underway by a multi-disciplinary team of ACC members and staff are bringing these tools to life.

This blog post is part of a series of blog posts during AFib Awareness Month. Stay tuned in the coming weeks for more information from the College on AFib news, tools and initiatives. Also visit ACC’s Facebook page for additional information.

What do Cardiologists and Football Have in Common?

One might not initially think that cardiologists and football players have a lot in common. However, coming out of the standing-room-only Board of Governors (BOG) meeting this past weekend, I can tell you that the team spirit and tireless work ethic of ACC’s cardiovascular “team” rivals that of the best players on the football field.

The September BOG Meeting is always one of my favorites. We’re moved beyond saying “here’s what we’re going to do” to “here’s what we’re doing.” It’s a time to look back on early accomplishments, reassess priorities if needed, and celebrate where we’re going.

Among the early accomplishments this year:

  • A formal recommendation regarding Appropriate Use Criteria terminology. The BOG has been an integral part of these discussions over the last several months and   we believe that the recommended changes will address many of the concerns raised by members at the grassroots level, particularly regarding the use of the term “Inappropriate.”
  • The development of a Digital Strategy. No, the BOG is not responsible for developing the Digital Strategy, but many governors have been involved in some manner in its development, whether it’s sharing feedback from Chapter members, actively taking part in usability testing or simply using the College’s online and mobile resources.
  • Participation in the Million Hearts initiative. We heard from Janet Wright, MD, FACC, executive director of Million Hearts, that the College and its Chapters are among the biggest contributors to Million Heart activities. As the initiative enters its second year, even more opportunities for involvement are expected.

Looking ahead, the College’s new Lifelong Learning Portfolio offers unprecedented new learning opportunities for ACC members. There are also incredible new quality improvement tools in development or newly launched that are intended to help cardiovascular professionals not only adhere to guidelines and best practices, but also involve patients in their care. Among these resources: Clinical Toolkits for atrial fibrillation and heart failure, and growing opportunities to use Imaging in FOCUS tools in practice. New CardioSmart initiatives like CardioSmartTV, which puts patient-themed content on waiting room televisions, offer up unique new ways to reach patients. As Dr. Wright also mentioned, we still have four more years to reach the Million Hearts goal of preventing one million heart attacks and strokes.

Of course, I’d be remiss not to mention some of the health policy issues ahead. There is no doubt that health reform implementation will continue to have impacts on the current practice environment, as will continued cuts to Medicare physician payment. There is a need for the entire cardiac care team to come together as one voice to make sure that policies moving forward are in the best interest of our patients. Issues like public reporting, the Physician Payment Sunshine Act and other policies being discussed will have profound impacts on how we practice and it’s important that the College and its members be heard.

This weekend reinforced that the ACC’s BOG is comprised of an amazing team of men and women who selflessly volunteer their time in many different ways, with the ultimate end goal of ensuring patients living with, or at risk of, heart disease are receiving the best, most appropriate care possible. Like the football teams who took to the field this weekend, we will take some hits and might even lose a few yards, but at the end of the day there’s a sense of accomplishment for all the yards run and the touchdowns that were made. As the old saying goes, we “come together, share together, work together and succeed together.”

AFib Awareness Month in Full Swing

The month of September is Atrial Fibrillation (AFib) Awareness Month. AFib is the most common arrhythmia in clinical practice affecting more than 2.2 million people in the U.S. and 4.5 million people in the European Union. As a result it is also an extremely costly public health problem, with roughly $3,600 as the global annual cost per patient.

Over the last 20 years there has been a 66 percent increase in hospital admissions for AFib. Some of the reasons for this increase include an aging population; increasing prevalence of chronic heart disease; and more frequent diagnosis thanks to improving technology. The rising obesity epidemic is also no doubt another factor.

As part of AFib Awareness Month, the College is focused on raising awareness about AFib among both clinicians and patients. According to the ACC/AHA AFib Guidelines, it’s very important that an overall management strategy be discussed with patients. This strategy should incorporate:
•    type and duration of AFib
•    associated symptoms
•    associated cardiovascular disease
•    effect of age and other medical conditions
•    cardiovascular risks of AFib
•    short-term and long-term treatment goals
•    pharmacological and nonpharmacological therapeutic options

Treatment options for patients at risk of stroke include anticoagulation of any type (vitamin K antagonist, direct thrombin inhibitors, Xa inhibitors) as indicated by guidelines, and their risks, side effects and benefits. There are now several options that are highly efficacious in reducing the risk of stroke. Several clinical trial updates recently addressed topics such as stroke rates in patients presenting to the emergency room with AFib and the impact on renal function of apixaban vs. warfarin in AFib patients. The WOEST trial at ESC, was the first randomized trial comparing clopidrogel with and without aspirin in patients on oral anticoagulant therapy who were undergoing PCI.

Unfortunately, there is still significant clinical underuse of anticoagulant therapies in AFib and misunderstandings about the safety and efficacy of novel anticoagulant agents. Furthermore, a recent CardioSurve survey found several key differences in the treatment of AFib around the globe. Cardiologists were surveyed from the US, Brazil, China, Germany, India and the UK, and showed that control over anticoagulation options varied by country. Physicians in the UK and China indicate that they have less control over the anticoagulation options available to patients. Costs and bleeding rate concerns are among the reasons for the difference. The College is currently in the early stages of developing a comprehensive initiative to address gaps in treatment and encourage compliance with guideline-recommended care.

On the patient front, CardioSmart offers patients tools to support them in their treatment and management of AFib. The AFib condition center on CardioSmart.org has background of the disease, the key facts, questions to ask a doctor and more. In addition, patient education videos include What You Need to Know About Stroke Risk and Why Your Rate and Rhythm Matter. Check out our “AF by the Numbers” infograph on CardioSmart’s Facebook page  and share with your patients.

This week the College launched its new AFib Clinical Toolkit, which provides tools and strategies for the patient care team to support high-quality care for patients with AFib in light of new therapies.

More on the AFib toolkit and other efforts by the College to continuously educate health care providers on the tried-and-true practices for AFib care through innovative educational programs will be discussed in the coming weeks here on the blog, so stay tuned!

This blog post is part of a series of blog posts during AFib Awareness Month. Stay tuned in the coming weeks for more information from the College on AFib news, tools and initiatives. Also visit ACC’s Facebook page for additional information.