Role of telemedicine in the management of oral anticoagulation in atrial fibrillation: a practical clinical approach

COVID-19; Direct oral anticoagulant; TelemedicineCOVID-19; Anticoagulante oral directo; TelemedicinaCOVID-19; Anticoagulant oral directe; TelemedicinaCompared with face-to-face consultations, telemedicine has many advantages, including more efficient use of healthcare resources, partial relief of the burden of care, reduced exposure to COVID-19, treatment adjustment, organization of more efficient healthcare circuits and patient empowerment. Ensuring optimal anticoagulation in atrial fibrillation patients is mandatory if we want to reduce the thromboembolic risk. Of note, telemedicine is an excellent option for the long-term management of atrial fibrillation patients. Moreover, direct oral anticoagulants may provide an added value in telemedicine (versus vitamin K antagonists), as it is not necessary to monitor anticoagulant effect or make continuous dosage adjustments. In this multidisciplinary consensus document, the role of telemedicine in anticoagulation of this population is discussed and practical recommendations are provided.V Barrios has received consultancy/lecture fees from Bayer, BMS/Pfizer, Boehringer Ingelheim and Daiichi Sankyo. S Cinza-Sanjurjo has received honoraria for presentations from Bayer, Boehringer-Ingelheim, Daiichi Sankyo and Pfizer-BMS; advisory board fees from Bayer, Boehringer-Ingelheim, Daiichi Sankyo and Pfizer-BMS; and funding for studies from Bayer. J García-Alegría reports consulting fees and/or lectures honoraria from Bayer, Boehringer Ingelheim, Bristol-Myers Squibb and Daiichi Sankyo. R Freixa-Pamias has received honoraria for presentations from Bayer, Boehringer-Ingelheim, Daiichi Sankyo and Pfizer-BMS. F Llordachs-Marques. No potential conflicts of interest were declared by the author. CA Molina reports consulting fees and/or honoraria from Novo Nordisk, Bayer, Pfizer, BMS, Daiichi Sankyo and Boehringer Ingelheim. A Santamaría has received honoraria per conferences from Octapharma, Novo Nordisk, Bayer, Pfizer, BMS, Sobi, Shire, Sanofi, LEO Pharma, Rovi, Daiichi Sankyo, Werfen and Ferrer. D Vivas reports no potential conflicts of interest were declared by the author. C Suárez has received speaker and/or advisory fees from Bayer, Pfizer/BMS, Daiichi Sankyo. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed

Study design of Heart failure Events reduction with Remote Monitoring and eHealth Support (HERMeS)

Aims: The role of non-invasive telemedicine (TM) combining telemonitoring and teleintervention by videoconference (VC) in patients recently admitted due to heart failure (HF) ('vulnerable phase' HF patients) is not well established. The aim of the Heart failure Events reduction with Remote Monitoring and eHealth Support (HERMeS) trial is to assess the impact on clinical outcomes of implementing a TM service based on mobile health (mHealth), which includes remote daily monitoring of biometric data and symptom reporting (telemonitoring) combined with VC structured, nurse-based follow-up (teleintervention). The results will be compared with those of the comprehensive HF usual care (UC) strategy based on face-to-face on-site visits at the vulnerable post-discharge phase. Methods and results: We designed a 24 week nationwide, multicentre, randomized, controlled, open-label, blinded endpoint adjudication trial to assess the effect on cardiovascular (CV) mortality and non-fatal HF events of a TM-based comprehensive management programme, based on mHealth, for patients with chronic HF. Approximately 508 patients with a recent hospital admission due to HF decompensation will be randomized (1:1) to either structured follow-up based on face-to-face appointments (UC group) or the delivery of health care using TM. The primary outcome will be a composite of death from CV causes or non-fatal HF events (first and recurrent) at the end of a 6 month follow-up period. Key secondary endpoints will include components of the primary event analysis, recurrent event analysis, and patient-reported outcomes. Conclusions: The HERMeS trial will assess the efficacy of a TM-based follow-up strategy for real-world 'vulnerable phase' HF patients combining telemonitoring and teleintervention

Impact of heart failure on the clinical profile and outcomes in patients with atrial fibrillation treated with rivaroxaban. Data from the EMIR study

Background: The aim of this study was to analyze the impact of the presence of heart failure (HF) on the clinical profile and outcomes in patients with atrial fibrillation (AF) anticoagulated with rivaroxaban. Methods: Observational and non-interventional study that included AF adults recruited from 79 Spanish centers, anticoagulated with rivaroxaban ≥ 6 months before inclusion. Data were analyzed according to baseline HF status. Results: Out of 1,433 patients, 326 (22.7%) had HF at baseline. Compared to patients without HF, HF patients were older (75.3 ± 9.9 vs. 73.8 ± 9.6 years; p = 0.01), had more diabetes (36.5% vs. 24.3%; p < 0.01), coronary artery disease (28.2% vs. 12.9%; p < 0.01), renal insufficiency (31.7% vs. 22.6%; p = 0.01), higher CHA2DS2-VASc (4.5 ± 1.6 vs. 3.2 ± 1.4; p < 0.01) and HAS-BLED (1.8 ± 1.1 vs. 1.5 ± 1.0; p < 0.01). After a median follow-up of 2.5 years, among HF patients, annual rates of stroke/systemic embolism/transient ischemic attack, MACE-non-fatal myocardial infarction, revascularization and cardiovascular death-, cardiovascular death, and major bleeding were 1.2%, 3.0%, 2.0%, and 1.4%, respectively. Compared to those patients without HF, HF patients had greater annual rates of MACE (3.0% vs. 0.5%; p < 0.01) and cardiovascular death (2.0% vs. 0.2%; p < 0.01), without significant differences regarding other outcomes, including thromboembolic or bleeding events. Previous HF was an independent predictor of MACE (odds ratio 3.4; 95% confidence interval 1.6-7.3; p = 0.002) but not for thromboembolic events or major bleeding. Conclusions: Among AF patients anticoagulated with rivaroxaban, HF patients had a worse clinical profile and a higher MACE risk and cardiovascular mortality. HF was independently associated with the development of MACE, but not with thromboembolic events or major bleeding

implantació d’un model d’Atenció Integrada de Cardiologia – Atenció Primària en l'abordatge de pacients amb malalties cardáques cròniques

Les malalties cardiovasculars són la principal causa de mortalitat i morbiditat en els països desenvolupats i la tendència és cap al seu augment, donat el progressiu envelliment de la població, l’augment dels factors de risc i la major supervivència dels pacients gràcies als avenços en la prevenció i el tractament. Aquest increment fa que augmenti la pressió assistencial sobre els diversos dispositius situats en diferents nivells assistencials, que els pacients siguin atesos per diferents professionals amb el risc de fragmentació de la seva atenció, duplicitat d’esforços diagnòstics i terapèutics, variabilitat de la pràctica clínica, múltiples desplaçaments i citacions. Per aquest motiu, cal fer un esforç de coordinació entre especialitats per aconseguir que aquests pacients tinguin la millor atenció mèdica en el millor nivell assistencial, en funció de l’estat de la seva malaltia, i així fer més eficient la continuïtat assistencial dels pacients amb malalties cardiovasculars. En aquesta tesi doctoral s’ha avaluat la implementació d’un nou model assistencial d’atenció integrada de cardiologia-atenció primària en el territori d’influència de l’hospital Moisès Broggi, basat en la comunicació i confiança entre els professionals sanitaris del territori, en el que s’inclou la integració d’un cardiòleg referent que es desplaça setmanalment al centre d’atenció primària, on fa visites presencials, consultories de casos clínics, resolució de dubtes diagnòstics o terapèutics per via presencial o telemàtica, activitats de formació mèdica continuada, disposa d’una història clínica compartida, així com de protocols de derivació i d’actuació consensuats. Aquest nou model assistencial ha permès millorar l’accessibilitat dels pacients a l’especialista de Cardiologia i ha reforçat el lideratge del metge de família en l’abordatge de les malalties cròniques cardiològiques, tenint el cardiòleg com a consultor i permetent que els cardiòlegs puguin centrar-se en atendre els pacients de recent diagnòstic o casos més complexes que requereixen un maneig més específic. L’atenció integrada ha ofert una millor qualitat assistencial als pacients amb malalties cròniques cardiològiques, aconseguint un increment significatiu del nombre de pacients amb cardiopatia isquèmica que assoleixen els objectius de tractament segons les recomanacions de les guies de pràctica clínica, un augment del nombre de pacients amb fibril·lació auricular que reben tractament anticoagulant oral i una reducció del nombre d’ictus isquèmics d’etiologia cardioembòlica en aquesta població. Aquest model ha facilitat que l’usuari pugui ser atès en el nivell assistencial més adequat, amb el recurs professional més efectiu, assegurant una millor continuïtat assistencial fruit d’una major coresponsabilitat, treball en equip i coordinació entre els cardiòlegs i els equips d’atenció primària.Las enfermedades cardiovasculares son la principal causa de mortalidad y morbilidad en los países desarrollados y la tendencia es a su aumento, dado el progresivo envejecimiento de la población, la alta prevalencia de factores de riesgo y la mayor supervivencia de los pacientes debido a los avances en la prevención y el tratamiento. Este aumento conlleva varias consecuencias como una mayor presión asistencial sobre los diferentes dispositivos situados en los diferentes niveles asistenciales, pacientes atendidos por diferentes profesionales con riesgo de fragmentación de su asistencia, duplicación de esfuerzos diagnósticos y terapéuticos, variabilidad de la práctica clínica, múltiples viajes y citas de los pacientes. En consecuencia, es necesario realizar un esfuerzo coordinado entre especialidades para conseguir que estos pacientes tengan la atención médica óptima, en el mejor nivel asistencial en función de la evolución de su enfermedad, y haciendo más eficiente la continuidad asistencial de los pacientes con enfermedades cardiovasculares. En esta tesis doctoral se ha evaluado la implementación de un nuevo modelo asistencial de atención integrada de cardiología-atención primaria en el territorio de influencia del hospital Moisès Broggi, basado en la comunicación y confianza entre los profesionales sanitarios del territorio , en el que se incluye la integración de un cardiólogo referente que se desplaza semanalmente en el centro de atención primaria, donde hace visitas presenciales, consultorías de casos clínicos, resolución de dudas diagnósticos o terapéuticos por vía presencial o telemática, actividades de formación médica continuada, dispone de una historia clínica compartida, así como de protocolos de derivación y de actuación consensuados. Este nuevo modelo asistencial ha permitido mejorar la accesibilidad de los pacientes al especialista de cardiología y ha reforzado el liderazgo del médico de familia en el abordaje de las enfermedades crónicas cardiológicas, teniendo el cardiólogo como consultor y permitiendo que los cardiólogos puedan centrarse en atender a los pacientes de reciente diagnóstico o casos más complejos que requieren un manejo más específico. La atención integrada ha ofrecido una mejor calidad asistencial a los pacientes con enfermedades crónicas cardiológicas, consiguiendo un incremento significativo del número de pacientes con cardiopatía isquémica que alcanzan los objetivos de tratamiento según las recomendaciones de las guías de práctica clínica, un aumento del número de pacientes con fibrilación auricular que reciben tratamiento anticoagulante oral y una reducción del número de ictus isquémicos de etiología cardioembólica en esta población. Este modelo ha facilitado que el usuario pueda ser atendido en el nivel asistencial más adecuado, con el recurso profesional más efectivo, asegurando una mejor continuidad asistencial fruto de una mayor corresponsabilidad, trabajo en equipo y coordinación entre los cardiólogos y los equipos de atención primariaCardiovascular disease is the leading cause of mortality and morbidity in developed countries and the trend is towards its increase, given the progressive aging of the population, the high prevalence of risk factors and the greater survival of patients due to advances in prevention and treatment. This increase entails several consequences as greater care pressure on the different resources located at different levels of care, patients being attended by different professionals with the risk of fragmentation of care, duplication of diagnostic and therapeutic efforts, the variability of clinical practice, multiple trips and patient citations. Consequently, it is necessary to make a coordinated effort between specialities to ensure that these patients have the optimal medical care, at the best level of care depending on the evolution of their disease, and making the continuity of care more efficient for patients with cardiovascular disease. This doctoral thesis has evaluated the impact of implementing a program integrating Cardiology and Primary care in the area of influence of Moisès Broggi Hospital, based on communication and trust between health professionals in its area of influence, which includes the integration of a referring cardiologist to each primary care centre. This professional attends patients every week, participates in the discussion of clinical cases, resolution of diagnostic or therapeutic doubts, ongoing medical education activities, shared electronic clinical history and the development of common protocols. Integrated care has improved the accessibility of patients to the cardiology specialist while strengthening the leadership of the general practitioners in addressing chronic cardiac diseases, having the cardiologist as a consultant and allowing cardiologists to focus on caring for newly diagnosed patients or more complex cases that require a more specific approach. This integral assistance model has offered a better quality of care to patients with chronic heart diseases, leading to a significant increase in the number of patients with ischemic heart disease who achieve treatment goals according to the recommendations of clinical practice guidelines, an increase in the number of patients with atrial fibrillation receiving oral anticoagulant treatment and a reduction in the number of atrial fibrillation-related ischemic stroke. This model has allowed the patient to receive medical care at the most appropriate level of care, with the most effective professional, ensuring better continuity of care as a result of greater co-responsibility, teamwork and coordination between cardiologists and general practitioners.Universitat Autònoma de Barcelona. Programa de Doctorat en Medicin

Role of telemedicine in the management of oral anticoagulation in atrial fibrillation: a practical clinical approach.

Compared with face-to-face consultations, telemedicine has many advantages, including more efficient use of healthcare resources, partial relief of the burden of care, reduced exposure to COVID-19, treatment adjustment, organization of more efficient healthcare circuits and patient empowerment. Ensuring optimal anticoagulation in atrial fibrillation patients is mandatory if we want to reduce the thromboembolic risk. Of note, telemedicine is an excellent option for the long-term management of atrial fibrillation patients. Moreover, direct oral anticoagulants may provide an added value in telemedicine (versus vitamin K antagonists), as it is not necessary to monitor anticoagulant effect or make continuous dosage adjustments. In this multidisciplinary consensus document, the role of telemedicine in anticoagulation of this population is discussed and practical recommendations are provided