Insertable cardiac monitoring to detect atrial fibrillation (AF) guides both immediate and long-term clinical management of patients at high risk for stroke, according to recently released results of the multicenter REVEAL AF clinical study in which Main Line Health participated in 2013.
The study found that physicians were more likely to change clinical management of patients who were newly diagnosed with AF detected by insertable cardiac monitors (ICM). Moreover, physicians were more likely to make those management changes in newly diagnosed patients at their first follow-up visits and for those who reported AF-associated symptoms.
“Previously it was believed that early identification of AF in ICM patients would lead to meaningful changes in management. The results of this study show that most physicians do indeed find ICM data actionable, and most react promptly,” said Peter Kowey, MD, a cardiologist at Lankenau Heart Institute, the William Wikoff Smith Chair in Cardiovascular Research at Lankenau Institute for Medical Research, and one of the study’s authors.
The REVEAL AF study enrolled 446 patients, of whom 387 underwent ICM insertion and met inclusion criteria. Of those, previously undetected AF was found in 115 patients. Within that cohort of 115 patients, 87 (76 percent) had a change in clinical management, 80 of which occurred at the first follow-up visit.
The two most common changes in clinical management were prescriptions for oral anticoagulation (OAC) therapy, prescribed 63 percent of the time, and rate and rhythm control medications, prescribed 23 percent of the time.
“We also found that physicians whose patients self-reported AF symptoms — including fatigue, dizziness and shortness of breath — at the first visit after AF detection were more likely to change clinical management,” said Dr. Kowey, who also served on the steering committee for the REVEAL-AF study. “These patients tended to have higher maximal daily AF burden and longer AF episodes.”
Additionally, while study participants frequently reported AF symptoms during follow-up — even among patients who were not diagnosed with AF — physicians changed clinical management more frequently in those participants who were diagnosed with AF and who were symptomatic.
“That was unexpected, as OAC initiation was the most common change in management, and stroke risk is similar with patients with and without AF-related symptoms,” the authors noted. “However, it is less surprising for the initiation of treatment with rate and/or rhythm control, where the benefits are largely symptom-driven.”
Dr. Kowey and his colleagues noted that the REVEAL-AF study “provides insights into how physicians handle treatment decisions in the face of knowledge gaps and in the absence of clear guideline recommendations.”
Dr. Kowey also noted that definitive information regarding the absolute benefit of anticoagulation in patients with incidentally discovered AF will be available with the completion of clinical trials that currently are in progress.
The results to date of the REVEAL-AF study were published in “Changes in Management Following Detection of Previously Unknown Atrial Fibrillation by an Insertable Cardiac Monitor (from the REVEAL AF Study)” in The American Journal of Cardiology.