Basic Do’s and Don’ts When Treating Patients with AF

Sometimes the goal in medicine is to push the envelope to drive sophisticated advances in patient care. At other times, the goal is simply to make sure that everyone is providing the minimal level of expected care. In an effort to “accelerate translation of scientific evidence into clinical practice”, the American College of Cardiology (ACC) and American Heart Association (AHA) have developed performance and quality measures for a variety of cardiac conditions. The latest measures for managing patients with atrial fibrillation (AF) were recently published in the Journal of the American College of Cardiology (JACC).¹ The ACC/AHA Task Force on Performance Measures distinguishes quality measures from performance measures in the document. Quality measures are described as “metrics that may be useful for local quality improvement but are not yet appropriate for public reporting or pay-for-performance programs”. In the ACC/AHA document, measures are also denoted as inpatient or outpatient. The measures are listed below, paraphrased, and consolidated for the purpose of simplification.

• Do:
  • Document CHA2DS2-VASc Risk Score
  • Prescribe anticoagulation in accordance with guideline recommendations
  • For patients prescribed warfarin, document planned PT/INR follow-up after discharge and schedule monthly INRs as outpatient 
  • Prescribe beta-blockers when LVEF ≤40
  • Prescribe ACEI or ARB when LVEF ≤40
  • Document shared decision making between physician and patient in anticoagulation prescription
• Don’t:
  • Prescribe antiarrhythmic drugs to patients with permanent AF for rhythm control
  • Prescribe dofetilide or sotalol in patients with AF and end-stage kidney disease or on dialysis
  • Prescribe direct thrombin or factor Xa inhibitor patients with AF with a mechanical heart valve
  • Prescribe direct thrombin and factor Xa inhibitor rivaroxaban or edoxaban in patients with AF and end-stage kidney disease or on dialysis
  • Prescribe both antiplatelet and oral anticoagulation therapy for patients who do not have coronary artery disease and/or vascular disease
  • Prescribe a nondihydropyridine calcium channel antagonist in patients with reduced ejection fraction
  • Treat patients with atrial fibrillation using catheter ablation who were not treated with anticoagulation therapy during or after a procedure

It is not clear how much these updated ACC/AHA atrial fibrillation measures will actually accelerate knowledge from bench to bedside, but at least they establish a bare minimum of care that should be delivered to patients with AF in and out of the hospital. The measures are evidence-based, difficult to challenge, and could reasonably be used to measure the quality of care of patients with AF and identify opportunities for improvement. Furthermore, they are concise, limited, and practical. Unlike some other efforts to improve quality, including massive registries that require entry of hundreds of data points, the writing committee stuck to their charge to “constructing measures that maximally capture important aspects of care quality…while minimizing, when possible, the reporting burden imposed on hospitals, practices, and practitioners.”¹

Reference

1. Heidenreich PA, Solis P, Estes N III, et al. 2016 ACC/AHA Clinical Performance and Quality Measures for Adults With Atrial Fibrillation or Atrial Flutter: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. J Am Coll Cardiol. 2016 June 24. doi:10.1016/j.jacc.2016.03.521