A Multidisciplinary Approach to Atrial Fibrillation Care: The Snyder Center for Comprehensive Atrial Fibrillation
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EP LAB DIGEST. 2024;24(8):1,20-21.
Carissa Pistilli, MSN, APRN; Dan L Musat, MD; Advay Bhatt, MD; Tina Sichrovsky, MD; Mark Preminger, MD; Mohammadali Habibi, MD; Stephanie Kochav, MD; Suneet Mittal, MD, Chair of the Cardiovascular Service Line
The Snyder Center, Valley Health System, Ridgewood, New Jersey
The purpose and motto of the Snyder Center is to bring evidence-based, team-directed, patient-centered care to patients with AF. To facilitate this collaborative approach, a system was created within its electrophysiology (EP) clinic to identify appropriate patients, create specific goals of treatment, and guide patients through the care journey.
Navigation of the complex care of AF was an initial goal for the center. This objective was achieved through the establishment of key roles, such as an AF coordinator and a dedicated nurse practitioner tasked with overseeing patient care. Referrals were received from various sources, including in-office consultations, hospital admissions, primary care practices, and cardiology offices directing patients to the Snyder Center for an evaluation of specific patient needs. This evaluation included aspects such as rate and rhythm control, risk factor modification, stroke prevention, and remote monitoring including smartphone-compatible devices. By providing a detailed road map, patients were empowered to make more informed decisions of available treatment options (Figure).
The approach to rate and rhythm control for each patient has centered around a meaningful discussion not only of controlling symptoms of AF but
improving quality of life. A shared decision-making process involving a detailed discussion about risks and benefits of each strategy is essential to optimize patient selection and guide through the different treatment modalities. Patients who are appropriate for rate control continue at the Snyder Center, allowing for ongoing monitoring of the quality and efficacy of rate control, and ultimately reducing the risk of cardiovascular compromise.
The role of the AF navigator is essential in guiding patients through the various options for rhythm control and monitoring their response to treatment. Comprehensive patient education on the safe administration of antiarrhythmic medications is provided. Evidenced-based practice has helped to guide patient selection for ablation and determine optimal timing for offering ablation as either a first- or second-line therapy.
Any discussion about rhythm control is complemented with a conversation about risk factor modification, the foundation of optimal AF management1 that requires the most teamwork and patient engagement. Therefore, a collaborative effort is utilized that includes the outpatient sleep center, weight loss clinic, and fitness center, as well as other established members of the patient care team, including the primary care physician and cardiologist.
Sleep apnea screening performed in the EP office prompts direct referrals for a sleep study and evaluation with a pulmonologist to determine treatment plans. Furthermore, a dedicated nutritionist for the Snyder Center is provided to patients to help achieve weight loss. If necessary, referrals for bariatric surgery or medically managed weight loss are coordinated with the weight loss clinic.
With the recent adoption of glucagon-like peptide-1 (GLP-1) receptor agonists for appropriate patients with cardiovascular disease such as AF, screening at the center for appropriate patients for this therapy has also been implemented. Patients are identified at first by a body mass index >30 and offered nutritionist consultation and, if appropriate, a consult for bariatric surgery. For those patients who have either failed diet and exercise on their own and have seen a nutritionist or who do not want bariatric surgery, a discussion is had about injectable weight loss drugs. They are encouraged to discuss this option with their primary care doctor, and more recently, the Snyder Center has been able to refer to our weight loss center to discuss this option as well.
Establishing open communication with the patients’ primary care team and cardiology team has improved collaborative treatment of other risk factors, including hypertension and diabetes.
With the development of an integrated care team dedicated to discussions and implementation of risk factor modification, the goal is to strive to maximize outcomes and provide a high standard of care for each AF patient.
In health care, there are many forces influencing the need to create digital transformation of care and provide continuous over episodic care. That need is highly apparent in the care of patients with AF. The digital health care landscape has provided new opportunities for better patient education, monitoring, and engagement. Innovative tools such as Rx.Health, a digital tool to provide pre- and post-operative instructions to patients via their cell phone, have been harnessed to ‘prescribe’ patient pathways via text message, allowing streamlined delivery of pre- and post-ablation care.
By utilizing the device clinic for cardiovascular implantable electronic device management, remote monitoring, and use of smartwatch and smartphone monitoring, patients are not only allowed to be more engaged in their own monitoring, but there is now a more proactive approach to manage AF recurrence. Encouraging patients to upload their electrocardiograms (ECGs) from an Apple Watch allows the care team to track cardiac tracings over time, enabling customization of individualized care plans.
Embracing digital health care and remote monitoring options has also led to more flexibility in stroke prevention and anticoagulation management options. Establishing stroke risk using the CHA2DS2-VASc score allows for appropriate treatment of high-risk patients with anticoagulation or left atrial appendage occlusion in cases where blood thinners are high risk in the long term. Low-risk patients are also identified, and in some cases, a loop recorder or smartwatch monitoring is used for notification of AF recurrences and the need for anticoagulation. Participation in the REACT-AF trial, an ongoing trial that began in July 2023 with expected completion in July 2029, which explores the use of Apple Watches for on-demand anticoagulation, exemplifies the center’s commitment to advancing patient care through innovative research.
For many patients, the treatment of AF is a marathon, with many forks in the road. Our multidisciplinary team approach that follows clear pathways, integrates evidence-based treatment modalities, and provides opportunities for patient engagement, empowers patients to navigate the AF journey.
Looking forward, our focus is on continuing to lead efforts to refine clinical and investigative efforts along the 4 pillars of management in AF patients, including ECG monitoring, stroke prevention, rhythm control, and risk factor modification.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest and report no conflicts of interest regarding the content herein. Dr Musat reports consulting fees with AltaThera and Medtronic. Dr Mittal reports payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events for Abbott and Medtronic, participation on a data safety monitoring board or advisory board with Abbott, Boston Scientific, Medtronic, iRhythm, and PaceMate.
Reference
1. Joglar J, Chung M, Armbruster AL, et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2024;83(1):109-279. doi:10.1016/j.jacc.2023.08.017
