Integrated chronic care management for patients with atrial fibrillation : a rationale for redesigning atrial fibrillation care

Atrial Fibrillation (AF) is a highly prevalent heart rhythm disturbance, often associated with underlying (cardio)vascular disease. Due to this the management of AF is often complex and current practice calls for a more comprehensive, multifactorial and patient-centred approach. Therefore an Integrated Chronic Care approach in AF was developed and implemented in terms of a nurse-led specialized outpatient clinic for patients with AF. A randomised controlled trial comparing the nurse-led approach with usual care demonstrated superiority in terms of cardiovascular hospitalization and death as well as cost-effectiveness in terms of Quality Adjusted Life Years (QALYs) and life years, in favour of the nurse-led approach. Implementing such approach can be difficult since daily practice can be persistent. To highlight the importance of integrated care wherein the nurse fulfils a significant role, and to provide a guide in developing and continuing such approach, this paper presents the theoretical framework of the AF-Clinic based on the principles of the Taxonomy for Integrated Chronic Atrial Fibrillation Management.Jeroen M L Hendriks, Harry J G M Crijns, Hubertus J M Vrijhoe

Stochastic series expansion method for quantum Ising models with arbitrary interactions

A quantum Monte Carlo algorithm for the transverse Ising model with arbitrary short- or long-range interactions is presented. The algorithm is based on sampling the diagonal matrix elements of the power series expansion of the density matrix (stochastic series expansion), and avoids the interaction summations necessary in conventional methods. In the case of long-range interactions, the scaling of the computation time with the system size N is therefore reduced from N^2 to Nln(N). The method is tested on a one-dimensional ferromagnet in a transverse field, with interactions decaying as 1/r^2.Comment: 9 pages, 5 figure

Psychometric properties of the Minnesota Living with Heart Failure Questionnaire (MLHF-Q)

Objective: To evaluate the psychometric properties of the Minnesota Living with Heart Failure Questionnaire (MLHF-Q) in patients with atrial fibrillation. Design: A prospective study of the patients who underwent DC electrical cardioversion. Setting: Clinics of cardiology and thoracic surgery of the University Hospital in Groningen, the Netherlands. Main outcome measures: The disease-specific MLHF-Q and generic measures of quality of life were administered. The sensitivity to change over time was tested with effect sizes (ES). Internal consistency of MLHF-Q scales was estimated with Cronbach's alpha. To evaluate the construct validity multitrait-multimethod analysis was applied. The 'known group validity' was evaluated by the comparison of mean scores and effect sizes between two groups of the New York Heart Association (NYHA) classification (NYHA I versus II-III). Stability of MLHF-Q scales was estimated in a subgroup of patients who remained stable. Perfect congruence analysis and factor analysis were applied to confirm the a priori determined structure. Results: Cronbach's alpha was :0.80 of the MLHF-Q scales. Perfect congruence analysis (PCA) showed that the results resemble quite well the a priori assumed factor structure. Multitrait-multi method analysis showed convergent validity coefficients ranging from 0.59 to 0.73 (physical impairment dimension) and 0.39 to 0.69 (emotional dimension). The magnitude of change can be interpreted as medium (ES = 0.50). The results of a 'test-retest' analysis in a stable group can be valued as satisfactory for the MLHF-Q scales (Pearson's r > 0.60). The physical dimension and the overall score of the MLHF-Q discriminated significantly between the NYHA I and II-III groups (p <0.001) with large effect sizes (ES > 1.0). Conclusions: The MLHF-Q has solid psychometric properties and the outcome of the current study indicates that the MLHF-Q is an effective and efficient instrument

Stroke risk in patients with device-detected atrial high-rate episodes

Cardiovascular implantable electronic devices (CIEDs) can detect atrial arrhythmias, i.e. atrial high-rate episodes (AHRE). The thrombo-embolic risk in patients showing AHRE appears to be lower than in patients with clinical atrial fibrillation (AF) and it is unclear whether the former will benefit from oral anticoagulants. Based on currently available evidence, it seems reasonable to consider antithrombotic therapy in patients without documented AF showing AHRE >24 hours and a CHA(2)DS(2)-VASc score (congestive heart failure, hypertension, age >= 75 years [doubled], diabetes mellitus, prior stroke [doubled], vascular disease, age 65-74 years and female sex) >= 1, awaiting definite answers from ongoing randomised clinical trials. In patients with AHR

Dronedarone in patients with congestive heart failure: insights from ATHENA

Dronedarone is a new multichannel blocking antiarrhythmic drug for treatment of atrial fibrillation (AF). In patients with recently decompensated congestive heart failure (CHF) and depressed LV function, the drug was associated with excess mortality compared with a placebo group. The present study aimed to analyse in detail the effects of dronedarone on mortality and morbidity in AF patients CHF. We performed a post hoc analysis of ATHENA, a large placebo-controlled outcome trial in 4628 patients with paroxysmal or persistent AF, to evaluate the relationship between clinical outcomes and dronedarone therapy in patients with stable CHF. The primary outcome was time to first cardiovascular (CV) hospitalization or death. There were 209 patients with NYHA class II/III CHF and a left ventricular ejection fraction &lt;0.40 at baseline (114 placebo, 95 dronedarone patients). A primary outcome event occurred in 59/114 placebo patients compared with 42/95 dronedarone patients [hazard ratio (HR) 0.78, 95% CI = 0.52-1.16]. Twenty of 114 placebo patients and 12/95 dronedarone patients died during the study (HR 0.71, 95% CI = 0.34-1.44). Fifty-four placebo and 42 dronedarone patients were hospitalized for an intermittent episode of NYHA class IV CHF (HR = 0.78, 95% CI = 0.52-1.17). In this post-hoc analysis of ATHENA patients with AF and stable CHF, dronedarone did not increase mortality and showed a reduction of CV hospitalization or death similar to the overall population. However, in the light of the ANtiarrhythmic trial with DROnedarone in Moderate to severe CHF Evaluating morbidity DecreAse study, dronedarone should be contraindicated in patients with NYHA class IV or unstable NYHA classes II and III CHF