Nurse-led atrial fibrillation clinics to ensure wide access to comprehensive disease management

This invited commentary refers to ‘Clinical service organisation for adults with atrial fibrillation: Cochrane systematic review and meta-analysis’, by C. Ferguson et al. https://doi.org/10.1093/eurjcn/zvaf113 Atrial fibrillation (AF) is the most prevalent sustained cardiac arrhythmia affecting up to 59 million individuals worldwide.1 The lifetime risk of AF ranges between 1 in 3–5 individuals after the age of 45 years.1 AF is associated with an increased risk of thrombo-embolic complications such as stroke, and other cardiovascular conditions such as heart failure, with risk increasing sharply with older age. Current management guidelines of the European Society of Cardiology (ESC) recommend a comprehensive treatment approach, summarized by the acronym CARE-AF:2 (C) treatment of underlying cardiovascular conditions, risk factors, and modification of lifestyle behaviour, (A) prevention of thrombo-embolic complications, (R) optimal rhythm management by applying a rate and/or rhythm control strategy, and (E) structured longitudinal re-evaluation and follow-up. Establishing frameworks for standardized care, streamlined workflows, and consistent application of evidence-based practices within organized clinical services is essential to ensure implementation of and adherence to broad recommendations for AF management, to ultimately improve patient outcomes. In this issue of the Eur J Cardiovasc Nurs, Ferguson et al.3 did a great effort to review the available literature to assess the effects of organized clinical service delivery models for AF on all-cause mortality and hospitalization, as well as cardiovascular outcomes, thrombo-embolic events, bleeding complications, quality of life, symptom burden, healthcare costs, and length of hospital stay. The authors need to be congratulated to conduct a broad systematic literature search including guideline-relevant Cochrane reports and several clinical trials. They showed that organized clinical services for AF likely lead to a large decrease in all-cause mortality but probably have minimal impact on all-cause hospitalization. Given the growing prevalence of AF and the shortage of physicians, several questions remain open: WHO should mainly deliver the patient care in clinical service organizations for AF? Nurse-led care approaches, where advanced practice providers such as nurse practitioners and physician assistants play a crucial role in managing routine follow-ups, patient education, and initial assessments under physician supervision, help to expand access and ensures continuity of care. Hendriks et al. showed that nurse-led physician-supervised care of patients with AF is superior to usual care provided by a cardiologist in terms of cardiovascular hospitalizations and cardiovascular mortality.4,5,6 However, despite growing evidence supporting nurse-led care approaches, establishing a nurse-led AF care clinic requires a change of vision. HOW should AF care be delivered? Specialized AF clinics seem to be best suited for the organization of comprehensive AF care. In such clinics, a patient-centred integrated care approach ensures the delivery of the best possible care through multidisciplinary approaches.7 AF clinics do not need to be linked to specific locations, but could also be set up in a remote setting. Integrating telemedicine and digital health tools can further optimize management, allowing healthcare providers to see and consult more patients efficiently while maintaining high-quality care. One example has been the TeleCheck-AF approach, which used a smartphone application for remote rhythm monitoring to allow teleconsultations in patients with AF.8,9 WHAT should nurse-led AF care focus on? There are several treatment challenges. Rhythm control by catheter ablation procedures, being the most effective treatment for AF, can just be offered to a minority of patients because of limited availability of specialized AF ablation centres. This obviously cannot be easily addressed and solved by nurse-led clinics. However, integrated multidisciplinary care pathways, including combined cardiometabolic risk factor modification and lifestyle interventions, are strongly promoted by guidelines as the first pillar of AF management. Exactly here, nurse-led AF clinics will be key to allow the wider clinical implementation of those guideline-recommended interventions. As also mentioned by Ferguson et al., further research is needed to determine the utility of organized clinical services for AF (nurse-led vs. non-nurse-led) while being treated according to guideline recommendations. Additionally, integrated registries mapping the patient journey and treatment processes will allow further refinement and improved efficiency and quality of novel transformative care approaches for the comprehensive management of AF. Eventually, in order to ensure broader implementation of nurse-led physician-supervised AF clinics, a curriculum for the (‘leading’) nurses as well as for the (‘supervising’) physicians, maybe flanked by a certification system and a combined clinical/research fellowship programme, will help to structure training for specialized AF nurses.9,10 Mandy V.M. Kessels (Conceptualization [lead], Writing—original draft [lead], Writing—review & editing [lead]), Dominik Linz (Conceptualization [supporting], Writing—original draft [supporting]), and Theo A.R. Lankveld (Writing—original draft [supporting]) None declared. none declared. No new data were generated or analysed in support of this research.