Treating Specialty and Outcomes in Atrial Fibrillation

Study Questions:

What is the association of treating specialty with atrial fibrillation (AF) outcomes among patients with newly diagnosed AF?

Methods:

The authors used a Veterans Administration study cohort in the TREAT-AF (Retrospective Evaluation and Assessment of Therapies in AF) trial to identify patients with newly diagnosed nonvalvular AF, who had at least one outpatient encounter with primary care or cardiology within 90 days of AF diagnosis. Cox proportional hazards regression was used to evaluate the association between treating specialty and AF outcomes.

Results:

Among 184,161 patients with newly diagnosed AF (age 70 ± 11 years; 1.7% women; CHA2DS2-VASc 2.6 ± 1.7), 40% received cardiology care, and 60% received primary care only. After adjustment for covariates, cardiology care was associated with reductions in stroke (hazard ratio [HR], 0.91; p < 0.001) and death (HR, 0.89; p <0.0001), and increases in hospitalizations for AF/supraventricular tachycardia (HR, 1.38; p < 0.0001) and myocardial infarction (MI) (HR, 1.03; p < 0.04). The propensity-matched cohort had similar results. In mediation analysis, oral anticoagulation (OAC) prescription within 90 days of diagnosis may have mediated reductions in stroke, but did not mediate reductions in survival.

Conclusions:

In patients with newly diagnosed AF, cardiology care was associated with improved outcomes, potentially mediated by early OAC prescription.

Perspective:

It is not entirely clear what drove the reductions in mortality in patients treated by cardiologists. Presumably, patients treated by cardiologists had more advanced cardiovascular disease, and the treatment of non-AF conditions may have contributed. It is also possible that patients with more prevalent and advanced noncardiac co-morbidities may not have been referred for specialty treatment. It is notable that OAC prescription likely played a role in reducing the risk of stroke, but OAC prescription did not appear to be responsible for mortality reductions in cardiology patients. It would be interesting to explore the impact of electrophysiology cardiologists, or AF treatment clinics, on these outcomes. Definitive data may only come from prospective randomized trials of AF treatment across various heath care settings.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Electrophysiology, Myocardial Infarction, Outcome Assessment (Health Care), Primary Health Care, Quality of Health Care, Risk, Stroke


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