Focused on the heart of the problem

Atrial Fibrillation (AF), the most common heart rhythm disorder, accounted for more than 72,000 hospitalisations in Australia during 2017 and 2018, and was associated with 9% of deaths in 2018. With the number of people with the condition forecast to rise, Flinders University researchers are approaching solutions from two completely different angles.

Professor Jeroen Hendriks, Flinders University Professor of Cardiovascular Nursing, says the expected increase in AF patients shifts the conversation from how AF can be prevented to how it can be best managed – and this will involve more patient involvement in lifestyle changes to manage improvement of their health.

“Invasive procedures can sometimes solve the problem, but if there is no response to the risk factors that trigger AF, then it will come back,” says Professor Hendriks. “Our immediate challenge is to monitor and prevent that from happening.”

AF is characterised by an irregular and often rapid heart rate that can increase the risk of stroke, heart failure and other heart-related complications.

To help reduce hospitalisations and deaths from this common heart condition, Professor Hendriks is leading a clinical trial that currently involves more than 200 patients at the Royal Adelaide Hospital’s outpatient services and clinical trial centre. Delivered in conjunction with the Central Adelaide Local Health Network (CAHLN), the Integrated Care (iCARE) AF Clinic uses a patient-centred approach to educate and empower people with AF to support selfmanagement of their care, which includes lifestyle modification.

“A multidisciplinary team including a nurse, cardiologist, the patient and their carer – and possibly other specialists, based on the individual patient cases – provides a comprehensive treatment approach that identifies risk factors such as obesity, sleep apnoea, high blood pressure or diabetes and puts in place a comprehensive treatment plan covering these aspects,” says Professor Hendriks. “It covers the treatment of AF, prevention of strokes and the management of risk factors and lifestyle modification – and it offers a new care model that could pave the way for future care and treatment delivery of AF patients.”

Professor Hendriks’ iCARE project shows that nurses in AF clinics can lead the way in care delivery, but emphasises that patients can’t just have passive acceptance of a doctor’s treatment; there is a need for patients to be onboard with changing and adapting their own lifestyle to assist the process and make it truly effective.

“It’s a big task. Most people have little idea about AF until they have an episode, so the iCARE clinics serve as a crucial resource to guide them. This model has proven that people are receptive and do want to learn more about AF, and to be successful the care package has to be as tailored to the individual as possible.”

Success with the initial iCARE trial has stimulated plans and funding applications to expand these clinics to other centres.

“The response from patients has reinforced my original hopes – that empowering the patients with more knowledge about AF is the first building block towards more efficient care delivery,” says Professor Hendriks. “It means they will only come back to hospitals in emergency situations, which is so important because the pressure that a growing number of AF patients will put on our hospital system is going to be enormous.”

He says an increased use of new technology also plays a key role, with decision-support technology, based on international guideline recommendations, guiding the clinical team through the care process. An educational booklet is available for patients, that provides information on AF, its symptoms and treatment, as well as risk factors and how to modify their lifestyle. They can also input incidents of AF and any other symptoms they are experiencing, which can help guide the iCARE-AF team in making treatment decisions.

“This suggests where we could do more – looking deeper into how digital technology can support patients and healthcare professionals.”

Professor Hendriks has been inspired by work done during COVID lockdowns with colleagues at Maastricht University in the Netherlands to perform remote monitoring of patients with AF by having patients put their finger over their mobile phone camera lens, enabling an app with PPG (photoplethysmography) software read their heart rate and rhythm. They had readings uploaded three times each day for a week to a cloud storage facility, giving doctors and nurses effective monitoring of these patients before teleconsultation appointments.

“It’s a simple intervention, but so effective – and now we are seeing hospitals across Europe embedding this in their daily practice. We found that patients were very conscientious about taking these readings and it was best used by older patients, which dispels thoughts that older people have resistance to using technology.”

While this represents a valuable new tool within a suite of measures to monitor AF, there is no magic bullet to cure the disease – which is why in another part of Flinders University, an electrophysiology team is exploring new ways of predicting outcomes of AF through an objective, biophysics-based approach to mapping and treatment.

Atrial fibrillation occurs due to chaotic electrical activation of the upper heart chambers. For most people, using the word chaotic suggests that AF is disorganised. The team is focused on identifying underlying patterns in the chaos, which allows certain kinds of predictions about AF. One such prediction is that the heart’s behaviour in the lead up to an AF incident – the so-called ‘pattern formation dynamics’ – should become statistically stable.

Identifying the orderliness within the apparent chaos holds promise of a new approach to understanding AF, with the team working on equations that can accurately predict AF incidents and validate these predictions in real time.

The ability to statistically characterise pattern dynamics with accuracy provides a foundation for governing equations in cardiac fibrillation. If AF can be accurately predicted it opens new options for tailored treatment.

Taking such a qualitative approach moves beyond conventional views but the team is confident these theories will lead to significant advances in predicting the factors that trigger AF.

Already the team has shown that the rates at which spiral waves are generated in AF converge to stable rates called renewal rates. They are dedicated to turning this insight into applications to improve treatment, especially ablation, to deliver more precise treatments for individual patients and ultimately save lives.