Anticoagulant Management for NVAF: Burden on Healthcare Systems - Episode 1
The Clinical and Financial Burden of NVAF
Peter Salgo, MD; Juvairiya Pulicharam, MD; Jaime E. Murillo, MD; and Ralph J. Riello III, PharmD, BCPS, remark on the clinical and financial burden of nonvalvular atrial fibrillation on the health system and consider the prevalence of heart failure in patients with NVAF.
Peter Salgo, MD: Hello, and thank you for joining this Pharmacy Times® Peer Exchange® panel discussion titled “Anticoagulant Management for Nonvalvular Atrial Fibrillation (NVAF): Burden on Healthcare Systems.” NVAF accounts for 95% of diagnosed cases of atrial fibrillation (AFib) in the United States. NVAF continues to impose a significant resource and cost burden on the United States healthcare system. The treatment goals in NVAF management are to prevent stroke, maintain sinus rhythm, and provide symptomatic relief. In this Peer Exchange®, I am joined by a group of highly esteemed colleagues. We’re going to talk about NVAF, in general, and stroke prevention because stroke prevention is crucial to reducing mortality and disability in patients with NVAF.
I am Dr. Peter Salgo. I am a professor of medicine and anesthesiology at Columbia University College of Physicians and Surgeons and associate director of surgical intensive care at the NewYork-Presbyterian Hospital in New York, New York. Participating today on our distinguished panel are Dr. Gary Besinque, pharmacist evidence analyst and strategist for Renal/Cardiovascular Health at Kaiser Permanente Drug Information Services—California Regions, in Santa Monica, California; Dr. Jaime Murillo, system director of noninvasive cardiology for Sentara Healthcare of Norfolk, Virginia; Dr. Riya Pulicharam, pediatrician and national medical director of population health and clinical outcomes for HealthCare Partners, a DaVita Medical Group, in Torrance, California; and Dr. Ralph Riello, cardiovascular critical care pharmacy specialist for the Coronary Intensive Care Unit at Yale New Haven Hospital in New Haven, Connecticut.
I want to thank all of you so much for being here. Let’s talk about the clinical burden and the cost burden of nonvalvular atrial fibrillation. It’s got to be high. What do you think? Tell me about that.
Juvairiya Pulicharam, MD: Atrial fibrillation is a high-cost disease state. When we look at any disease state, we have to look at the total health care cost, which includes direct and indirect costs.
Peter Salgo, MD: When we’re talking about direct costs, what are we talking about? What are the indirect costs? Parse this out for us.
Juvairiya Pulicharam, MD: Direct costs can be anything to do with office visits, emergency room visits, hospitalizations, and readmissions. Indirect costs are all the costs that are associated with the drugs—medical costs with other comorbidities, drug—drug interactions, and adverse events.
Peter Salgo, MD: That’s from the pharmaceutical side. To me, as a practitioner, when I think about atrial fibrillation and I think of direct costs, I think of stroke. I think that somebody is losing brain cells and quality of life. Is that a fair cost here? Is that a fair estimate?
Jaime E. Murillo, MD: Oh, absolutely. There’s no question about it. That’s probably where the main burden is—the fact that there are consequences associated with atrial fibrillation, not just an isolated event. I tell patients that atrial fibrillation is often like fever. It shows up, but you need to find out what’s associated with the fever, what’s causing the fever, and what the next possible consequences of it are. The other thing that I want to point out, in terms of burden, is the increasing prevalence of atrial fibrillation. People are living longer. As you know, mortality precludes morbidity. The prevalence has been estimated, by 2050, to be anywhere from 12 million to 15 million people. This number is higher than the current 3 million to 6 million people with atrial fibrillation.
Peter Salgo, MD: It’s going to double or triple? That’s a lot.
Jaime E. Murillo, MD: That’s a lot.
Peter Salgo, MD: We often think of atrial fibrillation as almost being benign. “Oh, he’s got AFib? So what.” How often do you see heart failure in these patients with AFib? I understand that this is a chicken-and-egg kind of question. Some people go into failure because they’re in fibrillation. Some people go into fibrillation because they’re in failure. What is the total burden of heart failure in these patients? Does anybody know?
Ralph J. Riello III, PharmD, BCPS: About half of all heart failure patients have AFib. About a third of all patients with AFIB have heart failure. Often, when you’re treating one condition, you cannot forget about the other. You’re absolutely right. It is the chicken and the egg. AFib begets AFib, but it also makes heart failure a lot worse. These patients with comorbid heart failure and AFib, regardless of whichever came first, are among those at highest risk for hospital readmissions. We know that’s a big-ticket item with the Centers for Medicare & Medicaid Services and penalties and moving to 90-day payer models in the future.
Peter Salgo, MD: Nothing like preload to improve your cardiac output.
Jaime E. Murillo, MD: There you go. In your practice, I’m sure that you’ve seen patients who have normal ejection fraction go into atrial fibrillation. The ejection fraction drops, and you cardiovert them back to normal. Then they go back into atrial fibrillation. It’s like a yo-yo, but there is a clear correlation between the two.
Peter Salgo, MD: I’ve got patients who are in AFib and they do everything right. They felt funny, so they went to see their doctor. It was discovered that they had AFib. They lost weight and exercised, but they just stayed in AFib. There are some patients for whom you just can’t get out of AFib. That’s an issue, isn’t it?
Jaime E. Murillo, MD: It is. It’s especially worse for those who are symptomatic. That’s where the problem is.