Development and Implementation of a Comprehensive Community-Based Atrial Fibrillation Clinic

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EP LAB DIGEST. 2025;25(1):1,8-10.

Andrew Rudnick, MD; Gautam Verma, MD; Laurie Marinaro-Pascale, CRNP; Meaghan Brown, CRNP; Andrew Giaquinto, PharmD 
Center for Atrial Fibrillation and Electrophysiology, Hunterdon Health, Flemington, New Jersey

Atrial fibrillation (AF) is the most common arrhythmia worldwide.¹ As people live longer, and with increasing rates of comorbid conditions such as obesity, diabetes, sleep apnea, and hypertension, AF is becoming more common.1 Despite clinical practice guidelines on diagnosis and management of AF, there remain substantial gaps in care.^2-4 These result in preventable morbidity, mortality, and cost. One of the main challenges in the management of AF derives from the complexity of these patients and their comorbidities. We created the Center for Atrial Fibrillation and Electrophysiology (CAFE) to treat these patients more effectively.

Structure 
CAFE functions as a practice within a practice. We are part of a large single-specialty cardiology practice in Hunterdon County, New Jersey. Within this framework, we have several staff members dedicated primarily to CAFE. These include 2 physicians, 2 advanced practice nurses (APNs), 1 pharmacist, 2 device clinic technicians, and several nurses functioning as patient navigators. Patients with AF are seen in specialty office space adjacent to the main cardiovascular practice. All arrhythmia-related office-based care can be performed there, including office visits, patient education, implantable loop recorder (ILR) implants, device checks, and pre- and post-procedure visits. Our exam rooms have video kiosks that allow for custom loading of educational videos, such as those highlighting left atrial appendage closure (LAAC) and ablation. Additionally, CAFE has participated in an episode-of-care program with a local insurer to reduce the overall cost of care. Finally, CAFE physicians regularly participate in formal and informal educational activities for cardiology mid-level providers, cardiologists, and primary care physicians in the system.

Workflow
CAFE is part of an integrated health care delivery system. AF may be diagnosed at multiple points of care within that system. Identification of AF at

any point within the system reflexively triggers referral directly to CAFE, facilitating rapid evaluation (Figure 1).

CAFE workflow is designed around the patient experience. As soon as a patient in the system is identified with AF, they are assigned an AF navigator, whose responsibility is to guide the patient through all the steps of their AF-related care. This begins with establishment of the patient within the clinic and continues longitudinally. We consider this relationship to be critical and assign this task only to experienced nurses with demonstrated ability to work closely and effectively with patients.

The initial consultation in CAFE is typically with an electrophysiologist, at which time, comorbid risk factors are identified and a plan is developed through a shared decision-making process. Because each patient’s situation is different, we are careful to design a plan that works best for the individual, acknowledging that there is often more than one way to approach their problems. 

Once a plan is developed, our clinic staff, including our navigator, APNs, and pharmacist follow our active patients continually between their visits with their physician. During this time, we focus attention on completing a workup, addressing comorbidities, reinforcing education, and encouraging compliance with treatment. The following example highlights this process.

Case Presentation
JM (not the patient’s real initials) is a 54-year-old man with obesity, hypertension maintained on lisinopril 20 mg daily, impaired fasting glucose, and former tobacco use who presented to the emergency department (ED) with palpitations lasting several hours and was seen to be in AF with rapid conduction. He spontaneously converted to sinus rhythm in the ED. He described that he had intermittently felt these palpitations for over a year but had never sought consultation. Prior to this index ED visit, the episodes had all spontaneously resolved within minutes. In the ED:

• Metoprolol succinate 25 mg daily was prescribed.
• A mobile cardiac telemetry monitor (MCT) was placed by ED staff.⁵
• He was referred to CAFE.
The MCT was configured to send data to CAFE, allowing review by clinic staff before his appointment.

Physician Appointment #1
At his appointment with an electrophysiologist in CAFE 2 days later, it became clear that there were several factors contributing to his AF: 

• Hypertension⁶
• Obesity⁶ (with body mass index [BMI] of 42.1 kg/m2)
• Physical inactivity^6,7
• Alcohol consumption⁸
• Likely obstructive sleep apnea (OSA) ⁹

He was informed of his CHA2DS2-VASc score10 of 1, and based upon this, anticoagulation was not recommended. His hypertension appeared to be well controlled, and he reported that he was tolerating the metoprolol. The decision was made at that time to continue metoprolol for the time being, given the severity of his symptoms. At the time of this initial visit, no further AF had been seen on MCT. His physician made several recommendations:

• Obtain an echocardiogram.^11-14
• Complete 14 days of MCT.
• Obtain a home sleep study.
• Ideally, eliminate alcohol use, or reduce it to no more than 3 drinks per week.^15-18 
• Review written information on AF.^19-20
• Consider options for weight loss15,^21-25 and exercise,21-25 including GLP-1 agonist therapy. 

Based upon shared decision-making, a rhythm control strategy was chosen. His navigator met with him, reinforcing the recommendations made by the physician, and helped him arrange the echocardiogram and sleep study.

Surveillance
His sleep study demonstrated an Apnea-Hypopnea Index (AHI) of 27.4, consistent with moderate OSA. This triggered consultation with sleep medicine, who recommended treatment with continuous positive airway pressure (CPAP). His echocardiogram was unremarkable, and his MCT demonstrated multiple short episodes of AF, most of which were associated with symptoms. His aggregate AF burden on MCT was 3%, during which time his average heart rate was 82 beats per minute (bpm).

APN Appointment #1
At his interval appointment 1 month later with an APN:

• The importance of exercise, weight loss, and limited alcohol use was reinforced.
• Risks and benefits of GLP-1 agonist therapy were reviewed. 
• Tirzepatide was prescribed.
• The prescription of tirzepatide triggered both a same-day consultation with the pharmacist as well as appointments for ongoing management by an APN trained in management of patients taking GLP-1 agonists.

Surveillance
Over the next several months, the patient lost 18 kg on tirzepatide and began to exercise, but continued to experience palpitations. The patient did not have objective ECG data during many of these episodes, so we could not tell whether (or how many) episodes represented AF.

APN Appointment #2
He saw the APN again after 3 months. At that time, he reported frustration with his ongoing AF, and requested ablation. He admitted that he was

not exercising as much as he had been advised but was remaining largely abstinent from alcohol. AF ablation risks and benefits were discussed, and he met directly with his navigator that day to plan his ablation and arrange follow-up with his electrophysiologist.

Physician Appointment #2
JM and his physician discussed his ongoing symptoms, and several options were reviewed, including ongoing lifestyle intervention, addition of antiarrhythmic drug therapy, and ablation. Collaboratively, they agreed to proceed with the ablation that had previously been discussed with the APN, and informed consent was obtained. In anticipation of ablation, he met again with his navigator, who began to arrange his computed tomography scan, confirmed the details of his ablation, and arranged post-procedure care and follow-up, including scheduling appointments and arranging a limited course of post-procedure anticoagulation.

Separately, his physician reinforced adherence to exercise, use of CPAP, and reduction in alcohol use.

JM reported that he was using a smartwatch to keep track of his rhythm during symptomatic episodes. His electrophysiologist reviewed the smartwatch tracings and agreed that it had correctly labeled AF episodes.²⁶ JM met with his navigator, who explained how to send these tracings to CAFE for inclusion in his electronic health record (EHR).

Over the next several weeks, JM sent several smartwatch tracings demonstrating recurrent AF.

AF Ablation
JM underwent AF ablation consisting of pulmonary vein isolation (PVI) with the cryoballoon at Morristown Medical Center by his CAFE physician, and was discharged home the same day. That night, he resumed the anticoagulant previously prescribed.

Site Check
Four days after his ablation, JM presented for his site check appointment with an APN. He reported slowly improving hoarseness after his ablation but offered no other complaints. Activity restrictions were reviewed, and post-ablation teaching was performed.

Surveillance
JM sent several transmissions that corresponded to palpitations. Review by his physician demonstrated multiple runs of atrial tachycardia, but no AF. These became progressively less frequent over the course of several weeks. A 14-day MCT monitor was placed 3 months after his ablation, demonstrating an AF burden of 0.1%. Notably, these short episodes of AF were largely not associated with symptoms.

Post-ablation Follow-up
At his 3-month post-ablation appointment with the physician, JM reported that his palpitations had dramatically improved. He admitted that he had stopped going to the gym, and his exercise now consisted mainly of walking his dog daily. His weight loss had plateaued, leaving him still obese (BMI of 35.4 kg/m2). His physician emphasized the importance of weight loss, exercise, limitation of alcohol, and CPAP use. His metoprolol was stopped, and follow-up was arranged for 6 months later. His navigator arranged another MCT monitor to be placed prior to this appointment.

Nine-month Follow-up
Nine months after his ablation, JM’s monitor demonstrated a persistently low AF burden (<0.1%). He reported only rare and very brief palpitations. His weight remained unchanged, and his exercise continued to consist of daily walks. At this appointment, his physician again reviewed the importance of weight loss, cardiopulmonary exercise, alcohol moderation, and CPAP adherence.

Annual Follow-up
JM has now presented twice for annual follow-up, reporting no change in symptoms. At his last appointment, he reported difficulty affording

tirzepatide, and he had a same-day consultation with the pharmacist,²⁷ who helped identify a discount program.

Discussion
This patient benefitted from several key features of CAFE:

• Direct integration of CAFE with key points of AF identification, in this case, the ED
• Ability to discharge the patient from the ED with a CAFE MCT monitor
• Immediate followed by longitudinal relationship with a nurse navigator
• Interval encounters with an EP nurse practitioner
• Availability of a clinical pharmacist
• Direct arrangement of sleep study, followed by reflex referral to sleep medicine
• Availability of a nurse practitioner trained in GLP-1 agonist management
• An EHR with the ability to import smartwatch tracings

Although the patient’s course was typical, people with AF can present with a variety of needs. Therefore, CAFE is also structured with workflows to provide multiple potential treatments for AF, including a directly integrated anticoagulation clinic, inpatient antiarrhythmic drug initiation (typically for dofetilide or sotalol), direct integration with the system device clinic, antiarrhythmic drug safety monitoring, integration with cardiothoracic surgeons for hybrid AF ablation, protocols for LAAC referral, implant, and follow-up, and same-day consultation.

In summary, CAFE has been structured to meet the varied needs of patients with AF. Direct integration as the sole center for AF management expertise in our health care system allows patient care to be streamlined. The center emphasizes team-based care that goes past the physician, including multiple other providers and support staff. By delivering high-quality best-practice care that is evidence-based, patient-centered, integrated, team-driven, and comprehensive, CAFE follows the principles for an AF Center of Excellence as described by the Heart Rhythm Society.²⁸ The use of an interdisciplinary team-based approach to AF management has been demonstrated to produce better outcomes, shorter wait times, more cost-effective care, fewer readmissions, and shorter lengths of stay.^29-34 Finally, feedback from referring physicians, patients, and their families has been overwhelmingly positive. 

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Giaquinto reports honorarium for presentation and a leadership role (unpaid) for the New Jersey Society of Health-System Pharmacists.

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