Factors associated with rhythm control treatment decisions in patients with atrial fibrillation-Insights from the NCDR PINNACLE registry
Factors associated with rhythm control treatment decisions in patients with atrial fibrillation-Insights from the NCDR PINNACLE registry
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DOI：
10.1016/j.ahj.2017.02.006
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发表时间：
2017-05-01
影响因子：
4.8
通讯作者：
Maddox, Thomas M.
中科院分区：
文献类型：
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作者：
Gehi, Anil K.;Doros, Gheorghe;Maddox, Thomas M.
背景 在房颤 (AF) 中使用节律控制的决定通常应根据患者因素决定，例如生活质量、心力衰竭和其他合并症。其他因素是否会影响有关使用心律控制（特别是导管消融）的决定尚不清楚。方法从 2008 年 5 月 1 日至 2014 年 12 月 31 日的研究期间，从国家心血管数据注册中心的美国门诊心脏病学实践的实践创新和临床卓越 (PINNACLE) AF 注册中确定了一组被诊断为非瓣膜性 AF 的所有患者。抗心律失常药物治疗或导管消融）进行了评估。我们评估了与节律控制相关的患者和实践因素，并确定了患者、实践和未测量的实践因素与其使用的相对贡献。结果 在 511,958 名 PINNACLE AF 患者中，22.3% 接受节律控制治疗，2.9% 接受导管消融治疗。节奏控制方面存在显着的练习差异（不同练习中节奏控制的中位率为 22.8%，范围为 0.2%-62.9%）。与节律控制治疗相关的重要患者因素包括白人（与非白人）种族（比值比 [OR] 2.43，P < .001）、私人（与非私人）保险（OR 1.04，P < .001）以及患者是否接受过电生理学家检查（OR 1.77，P < .001）。在对患者、实践和未测量的实践因素对心律控制的相对贡献进行分析时，未测量的实践因素（95% 范围或 0.29-3.44）的贡献超过了患者（95% 范围或 0.46-2.30）或实践（95% 范围或 0.15-2.77）因素。 结论 在 PINNACLE 登记中，五分之一的 AF 患者接受了心律控制， 50 人接受了导管消融术，这表明节律控制可能没有得到充分利用。与患者特征无关的各种测量和未测量的实践因素在节律控制治疗决策的使用中发挥着不成比例的作用。了解这些决策的驱动因素可以识别不适当的治疗变化，并更好地指导这些疗法的最佳使用。
Background Decisions to use rhythm control in atrial fibrillation (AF) should generally be dictated by patient factors, such as quality of life, heart failure, and other comorbidities. Whether or not other factors affect decisions about the use of rhythm control, and catheter ablation in particular, is unknown.Methods A cohort of all patients diagnosed with nonvalvular AF were identified from the National Cardiovascular Data Registry's Practice Innovation and Clinical Excellence (PINNACLE) AF registry of US outpatient cardiology practices during the study period from May 1, 2008, to December 31, 2014. Overall and practice-specific rates of rhythm control (cardioversion, antiarrhythmic drug therapy, or catheter ablation) were assessed. We assessed patient and practice factors associated with rhythm control and determined the relative contribution of patient, practice, and unmeasured practice factors with its use.Results Among 511,958 PINNACLE AF patients, 22.3% were treated with rhythm control and 2.9% underwent catheter ablation. Significant practice variation in rhythm control was present (median rate of rhythm control across practices 22.8%, range 0.2%-62.9%). Significant patient factors associated with rhythm control therapy included white (vs nonwhite) race (odds ratio [OR] 2.43, P < .001), private (vs nonprivate) insurance (OR 1.04, P < .001), and whether a patient was seen by an electrophysiologist (OR 1.77, P < .001). In an analysis of the relative contribution of patient, practice, and unmeasured practice factors with rhythm control, the contribution of unmeasured practice factors (95% range OR 0.29-3.44) exceeded that of either patient (95% range OR 0.46-2.30) or practice (95% range OR 0.15-2.77) factors.Conclusions One in 5 AF patients in the PINNACLE registry received rhythm control, and 1 in 50 received catheter ablation, suggesting that rhythm control may be underused. A variety of measured and unmeasured practice factors unrelated to patient characteristics play a disproportionate role in the use of rhythm control treatment decisions. Understanding the drivers of these decisions may identify inappropriate treatment variation and better inform optimal use of these therapies.