Impact of the atrial fibrillation better care pathway in clinically complex patients with atrial fibrillation: a report from the ESC-EHRA EORP-AF General Long-Term Registry

Abstract

Background Clinical complexity is increasingly prevalent among patients with atrial fibrillation (AF). The “Atrial fibrillation Better Care” (ABC) pathway approach has been proposed to streamline a more holistic and integrated approach to AF care; however, there are limited data on its usefulness among clinically complex patients. We analyzed the impact of the ABC pathway in a contemporary cohort of clinically complex AF patients. Methods From the ESC-EHRA EORP-AF General Long-Term Registry, we analyzed clinically complex AF patients, defined as the presence of frailty (according to a 40-items Frailty Index), multimorbidity and/or polypharmacy. A K-medoids cluster analysis was performed to identify different groups of clinical complexity. The impact of an ABC-adherent approach on the risk of all-cause death, major adverse cardiovascular events (MACEs) and the composite outcome of all-cause death and MACE was analyzed through Cox-regression analyses, and delay of event (DoE) analyses; number needed to treat (NNT) was also estimated at 1 year of follow-up. Results Among 9,966 AF patients, 8,289 (92.3%) were clinically complex. Risk of all outcomes was higher among clinically complex patient. Adherence to the ABC pathway in the clinically complex group reduced the risk of all-cause death (adjusted HR [aHR]: 0.71, 95% CI 0.57–0.89), major adverse cardiovascular events (MACEs, aHR: 0.68, 95% CI 0.53–0.87) and composite outcome (aHR: 0.69, 95% CI: 0.57–0.84). Using cluster analysis, we identified a high clinical complexity group of AF patients. Adherence to the ABC pathway was associated with a significant reduction in the risk of death (aHR: 0.73, 95% CI 0.55–0.96) and composite outcome (aHR: 0.69, 95% CI 0.57–0.84) in the high-complexity cluster; similar trends were observed for MACEs. In DoE analyses, an ABC-adherent approach resulted in significant gains in event-free survival for all-cause death (Figure 1), MACEs, and composite outcome in clinically complex patients. Based on absolute risk reduction at 1 year of follow-up, the NNTs for ABC pathway adherence was 24 for all-cause death, 31 for MACEs and 20 for the composite outcome. Conclusions An ABC-adherent approach reduces the risk of major outcomes in clinically complex AF patients. Ensuring adherence to the ABC pathway is essential to improve clinical outcomes amongst clinically complex AF patients. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Since the start of EORP, several companies have supported the programme with unrestricted grants.

Effects of the ABC pathway on clinical outcomes in a secondary prevention population of Chinese patients with atrial fibrillation: A report from the Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry

“…Adherence to just the “B” criterion was not associated with a significant reduction in the risk of the primary outcome of all‐cause death and major adverse cardiovascular events and adherence to the “A and C” criteria had a significantly lower risk compared to the “B and C” criteria. Nonetheless, the number of adverse events progressively decreased as the number of ABC criteria fulfilled increased with the lowest risk in those that were fully ABC adherent, highlighting that each component in the ABC pathway acts synergistically, and a holistic approach to AF management is best to improve patients' outcomes 22,23 . Thus, active measures to reinforce its uptake including education and awareness amongst healthcare professionals is necessary to better patient prognosis.…”

Mobile health technology integrated care in atrial fibrillation patients with diabetes mellitus in China: A subgroup analysis of the mAFA‐II cluster randomized clinical trial

“…Recent international guidelines have recommended its implementation as the cornerstone of the treatment of AF patients, 20 while previous evidence showed the effectiveness of adherence to the approach in improving outcomes of these subjects. 15,18,19 Nevertheless, the optimal treatment of DM clearly represents a key area of intervention for those AF patients who also have DM, and while retrospective studies have demonstrated the efficacy of the ABC pathway in reducing mortality and other adverse events in diabetic patients, 22 there is still uncertainty on whether a mHealth implemented-ABC pathway can improve prognosis of AF-DM patients. 30 The results of our analysis, which focused specifically on the interaction between DM and the effect of the mAFA intervention, show how the implementation of a patient-centred approach to the treatment of AF patients (as encompassed by the mAFA intervention) prescribed at the baseline, lead to a significant increase in the uptake of both anticoagulants (and specifically, NOACs) as well as DM-specific drugs, such as hypoglycaemic agents, and other agents used to treat associated conditions (including statins for dyslipidaemia and calcium-channel blockers for hypertension).…”

“…The ABC pathway has been proposed to streamline such a holistic approach, introducing a structured management and optimization of cardiovascular risk factors and comorbidities. Recent international guidelines have recommended its implementation as the cornerstone of the treatment of AF patients, 20 while previous evidence showed the effectiveness of adherence to the approach in improving outcomes of these subjects 15,18,19 …”

“…Adherence to the ABC pathway is associated with a reduction in mortality, stroke and bleeding, hence an improved prognosis in AF patients. [16][17][18][19] This has led the ABC pathway to be recommended in AF management guidelines. 20,21 Evidence in diabetic people with AF is more limited, although one post hoc analysis based on the Gulf SAFE Registry confirmed a substantial mortality risk reduction in ABC pathway compliant patients with DM, but also suggesting that most patients with DM and AF were not optimally treated despite their high risk of stroke.…”

“…This holistic or integrated care approach has been formulated as the “Atrial fibrillation Better Care” (ABC) Pathway 15 and consists of three pillars: Avoid stroke with appropriate anticoagulation (A); Better symptom management, through patient‐centred decisions on rate and rhythm control (B); and Cardiovascular and comorbidities management optimization, including lifestyle changes (C). Adherence to the ABC pathway is associated with a reduction in mortality, stroke and bleeding, hence an improved prognosis in AF patients 16–19 . This has led the ABC pathway to be recommended in AF management guidelines 20,21 .…”