Association of atrial fibrillation burden with rhythm control and stroke prevention interventions among patients with cardiac implantable electronic devices

Abstract

Abstract Background Prior analyses have demonstrated that persistent atrial fibrillation (PeAF) is associated with higher healthcare costs than paroxysmal AF (pAF) or permanent AF (PermAF). While clinical classification of AF is often inaccurate, assessing AF burden from cardiac implantable electronic devices (CIEDs) provides an opportunity to more accurately assess the mechanisms of cost differentials by type of AF. Objective To assess the rates of AF-specific healthcare interventions among patients with device detected pAF, PeAF and PermAF. Methods Using the de-identified Optum Clinformatics U.S. claims database (2015 to 2020) linked with the Medtronic CareLink database, we identified patients with newly implanted CIEDs that transmitted data 6 months post-implant (baseline period). Device monitoring data during baseline was utilized to stratify patients by AF burden category: pAF (at least one day with >5m AF but <7d with >23h AF), PeAF (at least 7 consecutive days with >23h AF) or PermAF (all days with >23h AF or >95% AF burden). Annualized rates of AF-specific interventions (cardioversions, ablations, hospitalizations for antiarrhythmic drug [AAD] loads, oral anticoagulation [OAC] prescription and AAD prescription) during follow-up were analyzed from insurance claims. Analyses were adjusted for geographical region, insurance type, CHA2DS2-VASc Score, and implant year. Results Of the 21,391 patients (72.9±10.9 yrs; 56.3% male) analyzed, 7,798 (36.5%) had device-detected AF. Among these, 5,966 (76.5%) were pAF (avg burden 2.9±8.6%), 1,145 (14.7%) were PeAF (avg burden 47.2±29.9%), and 687 (8.8%) were PermAF (avg burden 99.3±0.7%). Compared to patients with pAF, those with PeAF had a higher adjusted ratio of cardioversions, hospitalizations for new AAD initiation, OAC prescription and AAD prescription. Patients with PeAF also had higher adjusted rates of ablations, cardioversions, hospitalizations for new AAD initiation, and AAD prescriptions than those with PermAF. Compared to patients with pAF, those with PermAF had a lower adjusted rate of ablation, hospitalization for new AAD load and AAD prescription, but a higher rate of OAC prescription (fig). Conclusion In a real-world cohort, patients with CIED-detected PeAF had higher rates of cardioversions, hospitalizations for AAD initiation, and AAD prescriptions than those with CIED-detected pAF and PermAF. The higher intensity of observed physician-driven interventions may be a potential driver of the increased cost associated with PeAF.Figure