In the JournalsPerspective

Cardiology care soon after AF diagnosis tied to lower stroke risk

Mintu Turakhia
Mintu Turakhia

Patients with atrial fibrillation who received care from a cardiologist within 90 days after diagnosis had a decreased risk for stroke, according to a study published in the Journal of the American College of Cardiology.

“The important message here is that getting early cardiology care was associated with early prescription of drugs specifically for preventing stroke,” Mintu Turakhia, MD, MAS, associate professor of cardiovascular medicine and director of research at the Center for Digital Health at Stanford University in California and director of cardiac electrophysiology at the VA Palo Alto Health Care System, said in a press release. “These findings show that it is important to think of these interventions at the time of diagnosis.”

Care for patients with AF

Alexander C. Perino, MD , an internist at Stanford University, and colleagues reviewed data from 184,161 patients (median age, 70 years; 1.7% women) with newly diagnosed AF who were treated within the VA national health system between October 2003 and September 2012.

Patients received cardiology care (n = 69,901) if they went to a cardiology clinic and, if applicable, a primary care clinic within 90 days of diagnosis. Primary care (n = 114,260) was defined as care solely at a primary care clinic within 90 days of diagnosis.

Ischemic stroke was the primary outcome. Secondary outcomes were death and CV hospitalization, including for HF, AF or supraventricular tachycardia, MI, or transient ischemic attack.

After adjusting for covariates, patients who received cardiology care had a lower risk for overall mortality (HR = 0.89; 95% CI, 0.88-0.91), stroke (HR = 0.91; 95% CI, 0.86-0.96) and mortality within 30 days of CV hospitalization (HR = 0.88; 95% CI, 0.84-0.91) vs. those who received primary care. The risk for hospitalization for MI (HR = 1.03; 95% CI, 1-1.05) and AF or supraventricular tachycardia (HR = 1.38; 95% CI, 1.35-1.42) was higher in patients who received cardiology care compared with those who received primary care only.

A propensity-matched analysis, in which the researchers developed a propensity score using baseline covariates to predict probability of a patient being evaluated in a cardiology clinic, produced similar results.

Reduced risk with anticoagulants

Mediation analysis showed that patients prescribed oral anticoagulation treatment within 90 days of diagnosis had a trend toward reduced risk for stroke (indirect effect = 0.957; 95% CI, 0.909-1.007), but not for death; the same results were seen in the propensity-matched analysis.

“These findings warrant serious consideration of care pathways for patients with AF soon after diagnosis, identification of additional mediators of improved outcomes and exploration into the scalability of these interventions across health care delivery models,” Perino and colleagues wrote. “Streamlined care pathways for patients with AF will require integration into currently operating heath care systems and adaptation to ongoing system reform.”

In a related editorial, William Whang, MD, MS, clinical cardiac electrophysiologist at Mount Sinai Hospital in New York, wrote: “The study by Perino et al makes an important statement that cardiologists play a critical role in framing the decisions that patients face when diagnosed with AF. Despite the growing administrative hurdles and outside noise for us and our patients, we cannot forget that as choice architects, our efforts may make all the difference.” – by Darlene Dobkowski

Disclosures: Turakhia reports receiving research grants from Janssen Pharmaceuticals and Medtronic, and serving as a consultant/advisory board member for Abbott, Medtronic and St. Jude Medical. Perino and Whang report no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

 

Mintu Turakhia
Mintu Turakhia

Patients with atrial fibrillation who received care from a cardiologist within 90 days after diagnosis had a decreased risk for stroke, according to a study published in the Journal of the American College of Cardiology.

“The important message here is that getting early cardiology care was associated with early prescription of drugs specifically for preventing stroke,” Mintu Turakhia, MD, MAS, associate professor of cardiovascular medicine and director of research at the Center for Digital Health at Stanford University in California and director of cardiac electrophysiology at the VA Palo Alto Health Care System, said in a press release. “These findings show that it is important to think of these interventions at the time of diagnosis.”

Care for patients with AF

Alexander C. Perino, MD , an internist at Stanford University, and colleagues reviewed data from 184,161 patients (median age, 70 years; 1.7% women) with newly diagnosed AF who were treated within the VA national health system between October 2003 and September 2012.

Patients received cardiology care (n = 69,901) if they went to a cardiology clinic and, if applicable, a primary care clinic within 90 days of diagnosis. Primary care (n = 114,260) was defined as care solely at a primary care clinic within 90 days of diagnosis.

Ischemic stroke was the primary outcome. Secondary outcomes were death and CV hospitalization, including for HF, AF or supraventricular tachycardia, MI, or transient ischemic attack.

After adjusting for covariates, patients who received cardiology care had a lower risk for overall mortality (HR = 0.89; 95% CI, 0.88-0.91), stroke (HR = 0.91; 95% CI, 0.86-0.96) and mortality within 30 days of CV hospitalization (HR = 0.88; 95% CI, 0.84-0.91) vs. those who received primary care. The risk for hospitalization for MI (HR = 1.03; 95% CI, 1-1.05) and AF or supraventricular tachycardia (HR = 1.38; 95% CI, 1.35-1.42) was higher in patients who received cardiology care compared with those who received primary care only.

A propensity-matched analysis, in which the researchers developed a propensity score using baseline covariates to predict probability of a patient being evaluated in a cardiology clinic, produced similar results.

Reduced risk with anticoagulants

Mediation analysis showed that patients prescribed oral anticoagulation treatment within 90 days of diagnosis had a trend toward reduced risk for stroke (indirect effect = 0.957; 95% CI, 0.909-1.007), but not for death; the same results were seen in the propensity-matched analysis.

PAGE BREAK

“These findings warrant serious consideration of care pathways for patients with AF soon after diagnosis, identification of additional mediators of improved outcomes and exploration into the scalability of these interventions across health care delivery models,” Perino and colleagues wrote. “Streamlined care pathways for patients with AF will require integration into currently operating heath care systems and adaptation to ongoing system reform.”

In a related editorial, William Whang, MD, MS, clinical cardiac electrophysiologist at Mount Sinai Hospital in New York, wrote: “The study by Perino et al makes an important statement that cardiologists play a critical role in framing the decisions that patients face when diagnosed with AF. Despite the growing administrative hurdles and outside noise for us and our patients, we cannot forget that as choice architects, our efforts may make all the difference.” – by Darlene Dobkowski

Disclosures: Turakhia reports receiving research grants from Janssen Pharmaceuticals and Medtronic, and serving as a consultant/advisory board member for Abbott, Medtronic and St. Jude Medical. Perino and Whang report no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

 

    Perspective
    John D. Day MD, FHRS, FACC

    John D. Day

    This was a provocative study in that it is an observational study reporting that patients treated by cardiologists for their AF have better outcomes than those treated by primary care providers. As it was just an observational study, we cannot say that treatment by one group of physicians is better than the other. However, it does raise an interesting question of what is the best system of care for patients with AF.

    This study is important in that it studies systems of care. With the ever-increasing number of patients with AF, better systems of care are required to treat these patients. This study raises the question of whether an AF system of care, with better adherence to oral anticoagulation guidelines, might improve outcomes.

    With the ever-increasing number of patients with AF, we need more research identifying the best way to treat these patients in accordance to national treatment guidelines. Would it be best for these patients to be treated by primary care physicians, cardiologists or even a nurse-practitioner-led specialty clinic?
    This is an interesting study that raises more questions than it answers.

    • John D. Day, MD
    • Cardiologist
      Medical Director, Intermountain Heart Rhythm Specialists
      Intermountain Heart Institute, Salt Lake City
      Past President, Heart Rhythm Society

    Disclosures: Day reports serving as a consultant for Abbott, Biotronik and Boston Scientific.