APHRS NEWSLETTER

02 GETTING TO KNOWAPHRS LEADER

IN THIS ISSUE

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Chief Editor: Deputy Editor:

Anil Saxena

Kazuo Matsumoto

Managing Editors:Hsuan-Ming TsaoDavid HeavenPipin KojodjojoNwe NweSeiji Takatsuki Jae-Min ShimJacky ChanYuanning XuArisara SuwannakulPhan Dinh PhongAparna Jaswal

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12 APHRS 2020

06 INTRODUCTION TOCOMMUNITY AF CLINICIN SINGAPORE

EP FELLOWS COURSE2020 IN NEW DELHI

APHRS ALLIEDPROFESSIONAL COURSE2020

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GETTING TO KNOWTeo Wee Siong National Heart Centre Singapore and Mt Elizabeth Hospital

Past APHRS President (2016)

MBBS, M MED, FRCPED, FACC, FHRS, FAPHRS

Medicine appeared to be an interesting

career and noble profession, where one

could also help the sick. With cardiology, it

became interesting because we could

actually help people with acute myocardial

infarction and treat them well. When I

started my cardiology training,

electrophysiology was still in its infancy and

only surgical therapy was available. With

catheter ablation and device proliferation,

electrophysiologists could truly cure some of

these patients. No reward is better than the

satisfaction of curing someone who is

critically ill with incessant SVT or VT.

Similarly devices such as pacemakers and

CRT have improved the quality of life of

many patients.

Why did you choose to enter medicineand above all, prefer to specialise inelectrophysiology?

What do you regard to be the mostsignificant development in cardiacrhythm management?

Catheter ablation has been and remains the

most important therapy for patients with

arrhythmias who do not respond to initial

medical therapy. Devices have also

revolutionized the patients of

bradyarrhythmias, heart failure and sudden

death prevention.

What are your thoughts about some ofthe emerging technologies, and theway they will shape the future care ofarrhythmia patients?

I think Artificial intelligence will become

increasingly important but we must never

lose the art of interpreting and making sure

it still makes sense.

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For my medical career, my early teachers

such as Prof Ong Yong Yau in the Singapore

General Hospital and during my Cardiology

training, Prof Arthur Tan and Prof Chia Boon

Lock who were my mentors. Most

importantly , I value my EP training under Dr

George Klein in London, Ontario, Canada,

the most. Since then, I have been learning

from everyone, whether senior or junior as

there is always something useful that one

can learn to help our patients better.

Who inspire you the most in your lifeand why?

What is your best life advice, motto orfavorite quote?We try and try our best but sometimes it maynot be enough and that’s life.

Can you talk about an accomplishmentthat you're particularly proud of ?Starting the interventional electrophysiologyprogram in Singapore in 1991 which was alsothe first in South East Asia. It was difficult toconvince my cardiology colleagues initiallybut now EP is accepted as a vital part ofCardiology and we have trained many in theregion as well. Secondly was being a foundingmember of APHRS and helping to developthe organization to become what it is today.

If you can get to have a alternativecareer, what would it be and why?

Can’t think of having another career thatwould have given the satisfaction that I havenow.

Never give up on your ideals and principle.

Always try and not be afraid to fail.

What advice would you give to youryounger self?

What are your hobbies and interestsoutside of medicine?Listening to music and spending time with my

family.

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EP Fellows Course 2020in Fortis Escorts Heart Institute New DelhiB y : A p a r n a J a s w a l M D , D N B , F H R S , C C D S , F A C C , F E S C

Dr. Anil Saxena & Dr. Aparna Jaswal atFortis Escorts Heart Institute (FEHI), NewDelhi conducted an Electrophysiologycourse for fellows on 2 February, EPFellows Course 2020. The content of the course was specificallydesigned as a primer course for thecardiology residents and fellows who areinterested to pursue EP in various parts ofthe country. The emphasis was laid uponunderstanding the ECG andelectrophysiology maneuvers in theelectrophysiology laboratory duringvarious commonly encounteredarrhythmias. There is paucity of qualifiedelectrophysiologists in the country withonly about 200 formally registeredmembers in Indian Heart rhythm Society.

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There is a felt need to introduce the field ofEP to fresh cardiology residents early intheir career so that they develop interest inthis sub-speciality in their formative yearsas cardiovascular professionals. In absenceof such priming the chance of takingelectrophysiology as the main career pathbecomes very bleak given the relatively lowexposure to arrhythmia management inmost centers across the country providingcardiology training. The course wasenvisaged with this goal in mind. The course directors invited nationalfaculties from various parts of India alongwith Ms Carol June Gilbert, RN who hadbeen working with Dr Masood Akhtar forseveral decades. The emphasis was onintroducing the concepts behindarrhythmia analysis on ECG and thedeductive reasoning behind common EP

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maneuvers in the lab. The sessions includeddidactic lectures and interactive real worldcases for reinforcing the concepts taught.The concepts were introduced in ahierarchical format from historicalevolution of EP to introduction to EGManalysis and then more advanced EPmaneuvers. Emphasis was on commonlyencountered arrhythmias includingsupraventricular tachycardias, VT instructurally normal hearts as well asischaemic VT.

The course was very well attended by over

70 fellows from various parts of the

country. It was much appreciated and was a

stepping stone towards many more such

academic curricula. We intend to continue

this course as a regular feature annually

with interesting case presentations from

fellows so as to encourage them and

provide a platform for them to showcase

their work.

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Bringing specialist care to thecommunity

B y : B r i g i t t e F o n g Y e o n g W o o , B S c ( N u r s i n g ) , R N , M C l i n R e s &L I M T o o n W e i , M B B S , F R A C P , P h D

The implementation and evaluation of anadvanced practice nurse-led integrated atrialfibrillation clinic in the polyclinic

Why? Atrial fibrillation (AF) is the most commonarrhythmia in Singapore and in 2011, wasprevalent in 1.5% of adults (Omar et al.,2011). With an ageing population, itsattendant comorbidities and a heightenedawareness of the need to screen for AF,the prevalence of AF in Singapore willcontinue rising (Frost & Sullivan MarketResearch, 2010).

This coming AF epidemic portends aninevitable capacity shortage if currentmodels of costly hospital-based,physician-centric care persist. The latestEuropean Society of Cardiology (ESC)guidelines for the management of AFrecommends an integrated caremanagement approach (Kirchhof et al.,2016).

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Remarkably, in this randomisedcontrolled trial comparing this novelnurse-led integrated chronic careapproach and the usual care provided bycardiologists, after a 22-months offollow-up, there was a significantly lowernumber of cardiac hospitalisation in thenurse-led group (13.5% vs. 19.1%, hazardratio 0.66 95% CI 0.46-0.93). Current models of healthcare deliverywhich are hospital-based physician-centric, specifically cardiologists, arenotsustainable. To mitigate the risingburden on the healthcare system that isexpected from AF patients, newhealthcare models must be introduced toimprove access to care and delivery ofcoordinated care.

This approach is patient-centred,integrating significant elements of patientcare, directing collaboration betweenpertinent disciplines and engagingpatients in the treatment and lifestylemodification process (Hendriks, Crijns, &Vrijhoef, 2015). As an early response to the worldwide AFepidemic, an integrated chronic careprogramme for AF patientswasimplemented in the outpatient clinicof Maastricht University Medical Centre,in the Netherlands (Hendriks et al., 2012). Nurse specialists delivered the clinicalmanagement of AF patients guided by aClinical Decision Support Software(CardioConsult AF®) and supervised bycardiologists.

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What?

Reduce specialist outpatient clinic usagein the hospitals    

Improve healthcare providers’adherence to AF management guidelines

Facilitate patient activation byimproving patients’ knowledge of AF

Improve patient outcomes such asquality of life (QoL), satisfaction withcare, adherence to medication.

treadmill ECGs in the hospital are someunique features of the integrated AF clinic.With these technological tools, the APN, incollaboration with the family physician andcardiologist, optimises the treatment andcare for patients living with AF and theirexisting chronic conditions.

Expected results The implementation of the integrated AFclinic aims to:     

Implemented in September 2018, theintegrated AF clinic providesmultidisciplinary team-based care that isprimarily led by an advanced practicenurse (APN) (Figure 1). The integrated AFclinic is situated in Bukit Batok Polyclinic.These polyclinics are government fundedgroup practices that were set up to providesubsidised primary care, post-hospitaldischarge medical follow-up care,immunisation, basic diagnostic services,pharmaceutical services, health education,and health screening. Increasingly, thesePolyclinics play a pivotal role in chronicdisease management in the primary caresetting. The use of a decision support tool, web-based education (www.nice-af.wixsite.com/livingwithaf) developed toaugment patient education,teleconsultations with a cardiologist andfast-tracked appointments for specialisedinvestigations such as transthoracicechocardiogram, Holter studies or

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References 1. Hendriks, J. M., Crijns, H. J., & Vrijhoef, H. J (2015).Integrated chronic care management for patients withatrial fibrillation: a rationale for redesigning atrialfibrillation care. J Atr Fibrillation, 7(5), 1177.doi:10.4022/jafib.1177 2. Hendriks, J. M., de Wit, R., Crijns, H. J., Vrijhoef, H. J.,Prins, M. H., Pisters, R., .. . Tieleman, R. G. (2012).Nurse-led care vs. usual care for patients with atrialfibrillation: results of a randomized trial of integratedchronic care vs. routine clinical care in ambulatorypatients with atrial fibrillation. Eur Heart J, 33(21),2692-2699. doi:10.1093/eurheartj/ehs071 3. Kirchhof, P., Benussi, S., Kotecha, D., Ahlsson, A.,Atar, D., Casadei, B., . . . Zeppenfeld, K. (2016). 2016ESC Guidelines for the management of atrial fibrillationdeveloped in collaboration with EACTS. Europace,18(11), 1609-1678. doi:10.1093/europace/euw295 4. Omar, R., Teo, W. S., Foo, D., Han, C. K., Jamaluddin,A. N., Low, L. P., & Ong, T. K. (2011). Atrial Fibrillation inSingapore and Malaysia: Current Trends and FutureProspects. Journal of Arrhythmia, 27(3), 171-185.doi:http://dx.doi.org/10.1016/S1880-4276(11)80042-6 5. Frost & Sullivan Market Research (2010 ).Understanding the atrial fibrillation (AFib) market.Singapore Frost & Sullivan Pte Ltd

Implementation so far Since its inception, the integrated AF clinichas provided care to 115 patients livingwith AF and other coexisting chronicconditions. Among those who participatedin the evaluation of the integrated AFclinic’s service, significant improvementswere observed in the patients’ QoL (Z =26.50; p = 0.034), AF knowledge (Z =33.00; p = 0.036) and medicationadherence (Z = < 0.001; p = 0.014).Besides, healthcare providers’ adherenceto AF management guidelines wasobserved to improve (Z = 36.00; p = 0.010). While our results are preliminary andlonger follow up is needed to demonstrateany benefit in clinical outcomes, the highlevel of acceptance and the earlypositive  results has been encouraging. Weplan to further expand this service notonly in the current clinic, but also toreplicate it in other polyclinics in our area.