Integrated Care in Atrial Fibrillation: A Road Map to the Future

Abstract

Atrial fibrillation (AF) is the most commonly encountered arrhythmia in clinical practice with an epidemiological coupling appreciated with advancing age, cardiometabolic risk factors, and structural heart disease. This has resulted in a significant public health burden over the years, evident through increasing rates of hospitalization and AF-related clinical encounters. The resultant gap in health care outcomes is largely twinned with suboptimal rates of anticoagulation prescription and adherence, deficits in symptom identification and management, and insufficient comorbid cardiovascular risk factor investigation and modification. In view of these shortfalls in care, the establishment of integrated chronic care models serves as a road map to best clinical practice. The expansion of integrated chronic care programs, which include multidisciplinary team care, nurse-led AF clinics, and use of telemedicine, are expected to improve AF-related outcomes in the coming years. This review will delve into current gaps in AF care and the role of integrated chronic care models in bridging fragmentations in its management.

Keywords: anticoagulants; atrial fibrillation; chronic disease; delivery of health care; heart diseases.

Figure 1.

Trial evidence in atrial fibrillation (AF). Pictorial representation of captured evidence with regard to AF. Intrinsic limitations in randomized controlled trials (RCTs) and observational studies (OSs) limit application of study findings to underrepresented populations.

Figure 2.

Gaps in care between control and treatment groups with regard to atrial fibrillation (AF) care. Diagrammatic portrayal of differences in outcomes with regard to AF-related anticoagulation, symptomatology, and risk factor management in control and treatment groups across RCT and OS. Original sourced data from studies in the Table. AFEQT indicates Atrial Fibrillation Effect on Quality of Life; BP, blood pressure; CPAP, continuous positive airway pressure; HbA1c, glycosylated hemoglobin A1c; JAKQ, Jessa Atrial fibrillation Knowledge Questionnaire; OAC, oral anticoagulant; and TTE, transthoracic echocardiography.

Figure 3.

Optimized atrial fibrillation (AF) care. Best clinical practice with regard to the three domains of AF-related care. INR indicates international normalized ratio; OAC, oral anticoagulant; and VKA, vitamin K antagonist.

Figure 4.

Atrial fibrillation (AF)–related expenditure. Pictorial breakdown of AF-related expenditure in the Australian health care system. Percentages rounded to closest integer number. Data derived from PricewaterhouseCoopers.

Figure 5.

The atrial fibrillation (AF) medical neighborhood. Hypothetical integrated medical neighborhood of an individual living with AF. Available support systems include primary, auxiliary, and tertiary levels of care with involvement of the primary care physician, pharmacist, cardiologist, electrophysiologist, family/carer, as well as auxiliary programs focused on risk factor modification.

Figure 6.

Atrial fibrillation (AF) integrated chronic care models. Theoretical integrated care framework for management of an individual living with AF. The schema shows utilization of integrated care principles across different health care settings and providers, with special focus on anticoagulation, symptom management, and risk factor control. AVN indicates atrioventricular node; CPAP, continuous positive airway pressure; PPM, permanent pacemaker; PVI, pulmonary vein isolation; and RFM, risk factor modification.