Abstract 11541: Optimizing the Management of High Risk Patients with Atrial Fibrillation: Promising Signs From the Standard versus Atrial Fibrillation Specific ManagemenT Study (SAFETY)
Background: Chronic atrial fibrillation (AF) is increasing in ageing populations with declining age-adjusted case-fatality rates for heart disease. The associated burden of morbidity and mortality is often linked to stroke and chronic heart failure (CHF).
Methods: SAFETY is a multicentre, randomized controlled trial of a nurse-led, home-based, AF-specific management program versus usual post-discharge care, in typically old and fragile patients discharged from hospital with chronic AF (but not CHF). We report on the risk profile of the first 104 (target 320) patients randomized into the study.
Results: Mean age was 72 ± 12 years and 51% are male, with 70% and 30% being initially managed as “rate” versus “rhythm” control at hospital discharge (mean heart rate 76 ± 17 vs. 68 ± 12 beats/minute, respectively). Common co-morbidity includes hypertension (79%), coronary artery disease (29%), diabetes (31%) and stroke (17%) and 89% have left atrial enlargement. Median (IQR) CHA2DS2-VASc score was 4 (0 to 8) and 57%, 6% and 29% respectively, were prescribed anticoagulation therapy, combined clopidogrel and aspirin or aspirin alone; 31% and 5% were prescribed digoxin or amiodarone. Montreal Cognitive Assessment scores at baseline showed 78% had mild cognitive impairment likely to impair ability to self-care and only 2 of 28 (7%) SAFETY intervention patients prescribed anti-coagulant therapy were adjudged capable of self-monitoring INR's and regulating therapy. Similarly, continuous 24 hour ECG Holter monitoring at the intervention home visit revealed only 16 (44%) had controlled heart rate while 20% and 36%, respectively, had uncontrolled or labile rate or rhythm control. Overall, 32% and 64% of SAFETY intervention patients were assessed as moderate and high risk, of readmission and/or death, respectively, triggering more intensive treatment/management.
Conclusions: In a real-world cohort of hospitalized patients with chronic AF, the conundrum of maximizing the benefit of potentially harmful therapeutics in high risk patients is obvious. The potential for the SAFETY intervention to achieve a balanced approach to management and, therefore, reduce morbidity and mortality relative to usual post-discharge care is also obvious.
- © 2011 by American Heart Association, Inc.