Clinical complexity and impact of the ABC (Atrial fibrillation Better Care) pathway in patients with atrial fibrillation: a report from the ESC-EHRA EURObservational Research Programme in AF General Long-Term Registry. - 2022
Clinical complexity and impact of the ABC (Atrial fibrillation Better Care) pathway in patients with atrial fibrillation: a report from the ESC-EHRA EURObservational Research Programme in AF General Long-Term Registry.
[en] [en] 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 aim to determine the impact of ABC pathway in a contemporary cohort of clinically complex AF patients.
METHODS: From the ESC-EHRA EORP-AF General Long-Term Registry, we analysed clinically complex AF patients, defined as the presence of frailty, 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 major outcomes was analysed through Cox-regression analyses and delay of event (DoE) analyses.
RESULTS: Among 9966 AF patients included, 8289 (83.1%) were clinically complex. Adherence to the ABC pathway in the clinically complex group reduced the risk of all-cause death (adjusted HR [aHR]: 0.72, 95%CI 0.58-0.91), major adverse cardiovascular events (MACEs; aHR: 0.68, 95%CI 0.52-0.87) and composite outcome (aHR: 0.70, 95%CI: 0.58-0.85). Adherence to the ABC pathway was associated with a significant reduction in the risk of death (aHR: 0.74, 95%CI 0.56-0.98) and composite outcome (aHR: 0.76, 95%CI 0.60-0.96) also 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 the outcomes investigated in clinically complex patients. Based on absolute risk reduction at 1 year of follow-up, the number needed to treat 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 among clinically complex AF patients.
Disciplines :
Cardiovascular & respiratory systems
Author, co-author :
Romiti, Giulio Francesco; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, William Henry Duncan Building, 6 West Derby St, Liverpool, L7 8TX, UK ; Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
Proietti, Marco; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, William Henry Duncan Building, 6 West Derby St, Liverpool, L7 8TX, UK ; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy ; Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
Vitolo, Marco; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, William Henry Duncan Building, 6 West Derby St, Liverpool, L7 8TX, UK ; Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy ; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
Bonini, Niccolò; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, William Henry Duncan Building, 6 West Derby St, Liverpool, L7 8TX, UK ; Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
Fawzy, Ameenathul Mazaya; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, William Henry Duncan Building, 6 West Derby St, Liverpool, L7 8TX, UK
Ding, Wern Yew; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, William Henry Duncan Building, 6 West Derby St, Liverpool, L7 8TX, UK
Fauchier, Laurent; Service de Cardiologie, Centre Hospitalier Universitaire Trousseau, Tours, France
Marin, Francisco; Department of Cardiology, Hospital Universitario Virgen de la Arrixaca, IMIB-Arrixaca, University of Murcia, CIBER-CV, Murcia, Spain
Nabauer, Michael; Department of Cardiology, Ludwig-Maximilians-University, Munich, Germany
Dan, Gheorghe Andrei; University of Medicine, 'Carol Davila', Colentina University Hospital, Bucharest, Romania
Potpara, Tatjana S; School of Medicine, University of Belgrade, Belgrade, Serbia ; Intensive Arrhythmia Care, Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
Boriani, Giuseppe; Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
Lip, Gregory Y H ; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, William Henry Duncan Building, 6 West Derby St, Liverpool, L7 8TX, UK. gregory.lip@liverpool.ac.uk ; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark. gregory.lip@liverpool.ac.uk
ESC-EHRA EORP-AF General Long-Term Registry Investigators
Sprynger, Muriel ; Université de Liège - ULiège > Département des sciences cliniques
Language :
English
Title :
Clinical complexity and impact of the ABC (Atrial fibrillation Better Care) pathway in patients with atrial fibrillation: a report from the ESC-EHRA EURObservational Research Programme in AF General Long-Term Registry.
Since the start of EORP, the following companies have supported the programme:
Abbott Vascular Int. (2011–2021), Amgen Cardiovascular (2009–
2018), AstraZeneca (2014–2021), Bayer (2009–2018), Boehringer Ingelheim
(2009–2019), Boston Scientific (2009–2012), The Bristol Myers Squibb and
Pfizer Alliance (2011–2016), The Alliance Daiichi Sankyo Europe GmbH and Eli
Lilly and Company (2011–2017), Edwards (2016–2019), Gedeon Richter Plc.
(2014–2017), Menarini Int. Op. (2009–2012), MSD-Merck & Co. (2011–2014),
Novartis Pharma AG (2014–2020), ResMed (2014–2016), Sanofi (2009–2011),
SERVIER (2010–2021), Vifor (2019–2022).
Woolford SJ, Aggarwal P, Sheikh CJ, Patel HP. Frailty, multimorbidity and polypharmacy. Medicine (United Kingdom). 2021;49:166–72.
Gallagher C, Nyfort-Hansen K, Rowett D, Wong CX, Middeldorp ME, Mahajan R, et al. Polypharmacy and health outcomes in atrial fibrillation: a systematic review and meta-analysis. Open Heart. 2020;7:e001257.
Chen N, Alam AB, Lutsey PL, Maclehose RF, Claxton JS, Chen LY, et al. Polypharmacy, adverse outcomes, and treatment effectiveness in patients ≥75 with atrial fibrillation. J Am Heart Assoc. 2020;9:15089.
Jani BD, Nicholl BI, McQueenie R, Connelly DT, Hanlon P, Gallacher KI, et al. Multimorbidity and co-morbidity in atrial fibrillation and effects on survival: findings from UK Biobank cohort. Europace. 2018;20:f329–36. DOI: 10.1093/europace/eux322
Proietti M, Cesari M. Describing the relationship between atrial fibrillation and frailty: clinical implications and open research questions. Exp Gerontol. 2021;152:111455.
Proietti M, Marzona I, Vannini T, Tettamanti M, Fortino I, Merlino L, et al. Long-term relationship between atrial fibrillation, multimorbidity and oral anticoagulant drug use. Mayo Clin Proc. 2019;94:2427–36. DOI: 10.1016/j.mayocp.2019.06.012
Chao TF, Joung B, Takahashi Y, Lim TW, Choi EK, Chan YH, et al. 2021 Focused update consensus guidelines of the Asia Pacific Heart Rhythm Society on stroke prevention in atrial fibrillation: executive summary. Thromb Haemost. 2022;122:20-47.
Hindricks G, Potpara T, Dagres N, Bax JJ, Boriani G, Dan GA, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2021;42:373–498. DOI: 10.1093/eurheartj/ehaa612
Potpara TS, Lip GYH, Blomstrom-Lundqvist C, Boriani G, van Gelder IC, Heidbuchel H, et al. The 4S-AF scheme (stroke risk; symptoms; severity of burden; substrate): a novel approach to in-depth characterization (rather than classification) of atrial fibrillation. Thromb Haemost. 2021;121:270–8. DOI: 10.1055/s-0040-1716408
Lip GYH. The ABC pathway: an integrated approach to improve AF management. Nat Rev Cardiol. 2017;14:627–8. DOI: 10.1038/nrcardio.2017.153
Proietti M, Romiti GF, Olshansky B, Lane DA, Lip GYH. Improved outcomes by integrated care of anticoagulated patients with atrial fibrillation using the simple ABC (Atrial Fibrillation Better Care) pathway. Am J Med. 2018;131:1359–1366.e6. DOI: 10.1016/j.amjmed.2018.06.012
Yoon M, Yang PS, Jang E, Yu HT, Kim TH, Uhm JS, et al. Improved population-based clinical outcomes of patients with atrial fibrillation by compliance with the simple ABC (Atrial Fibrillation Better Care) pathway for integrated care management: a nationwide cohort study. Thromb Haemost. 2019;119:1695–703. DOI: 10.1055/s-0039-1693516
Pastori D, Farcomeni A, Pignatelli P, Violi F, Lip GY. ABC (Atrial fibrillation Better Care) pathway and healthcare costs in atrial fibrillation: the ATHERO-AF study. Am J Med. 2019;132:856–61. DOI: 10.1016/j.amjmed.2019.01.003
Proietti M, Lip GYH, Laroche C, Fauchier L, Marin F, Nabauer M, et al. Relation of outcomes to ABC (Atrial Fibrillation Better Care) pathway adherent care in European patients with atrial fibrillation: An analysis from the ESC-EHRA EORP Atrial Fibrillation General Long-Term (AFGen LT) Registry. Europace. 2021;23:174–83. DOI: 10.1093/europace/euaa274
Proietti M, Romiti GF, Olshansky B, Lane DA, Lip GYH. Comprehensive management with the abc (Atrial fibrillation better care) pathway in clinically complex patients with atrial fibrillation: A post hoc ancillary analysis from the affirm trial. J Am Heart Assoc. 2020;9:e014932. DOI: 10.1161/JAHA.119.014932
Guo Y, Lane DA, Wang L, Zhang H, Wang H, Zhang W, et al. Mobile health technology to improve care for patients with atrial fibrillation. J Am Coll Cardiol. 2020;75:1523–34. DOI: 10.1016/j.jacc.2020.01.052
Romiti GF, Pastori D, Rivera-Caravaca JM, Ding WY, Gue YX, Menichelli D, et al. Adherence to the “Atrial Fibrillation Better Care” pathway in patients with atrial fibrillation: impact on clinical outcomes-a systematic review and meta-analysis of 285,000 patients. Thromb Haemost. 2022;122:406–14. DOI: 10.1055/a-1515-9630
Boriani G, Proietti M, Laroche C, Fauchier L, Marin F, Nabauer M, et al. Contemporary stroke prevention strategies in 11 096 European patients with atrial fibrillation: a report from the EURObservational Research Programme on Atrial Fibrillation (EORP-AF) Long-Term General Registry. Europace. 2018;20:747–57. DOI: 10.1093/europace/eux301
Boriani G, Proietti M, Laroche C, Fauchier L, Marin F, Nabauer M, et al. Association between antithrombotic treatment and outcomes at 1-year follow-up in patients with atrial fibrillation: The EORP-AF General Long-Term Registry. Europace. 2019;21:1013–22. DOI: 10.1093/europace/euz032
Mitnitski AB, Mogilner AJ, Rockwood K. Accumulation of deficits as a proxy measure of aging. ScientificWorldJournal. 2001;1:323–36. DOI: 10.1100/tsw.2001.58
Rockwood K, Mitnitski A. Frailty in relation to the accumulation of deficits. J Gerontol - Ser A Biol Sci Med Sci. 2007;62:722–7. DOI: 10.1093/gerona/62.7.722
Dent E, Kowal P, Hoogendijk EO. Frailty measurement in research and clinical practice: a review. Eur J Intern Med. 2016;31:3–10. DOI: 10.1016/j.ejim.2016.03.007
Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. What is polypharmacy? A systematic review of definitions. BMC Geriatr. 2017;17:230. DOI: 10.1186/s12877-017-0621-2
Koenker R. Quantile Regression. Cambridge: Cambridge University Press; 2005. DOI: 10.1017/CBO9780511754098
Hong HG, Christiani DC, Li Y. Quantile regression for survival data in modern cancer research: expanding statistical tools for precision medicine. Precis Clin Med. 2019;2:90–9. DOI: 10.1093/pcmedi/pbz007
Lytsy P, Berglund L, Sundström J. A proposal for an additional clinical trial outcome measure assessing preventive effect as delay of events. Eur J Epidemiol. 2012;27:903–9. DOI: 10.1007/s10654-012-9752-0
Proietti M, Romiti GF, Raparelli V, Diemberger I, Boriani G, Dalla Vecchia LA, et al. Frailty prevalence and impact on outcomes in patients with atrial fibrillation: a systematic review and meta-analysis of 1,187,000 patients. Ageing Res Rev. 2022;79:101652.
Kozieł M, Simovic S, Pavlovic N, Kocijancic A, Paparisto V, Music L, et al. Impact of multimorbidity and polypharmacy on the management of patients with atrial fibrillation: insights from the BALKAN-AF survey. Ann Med. 2021;53:17–25. DOI: 10.1080/07853890.2020.1799241
Proietti M, Esteve-Pastor MA, Rivera-Caravaca JM, Roldán V, Roldán Rabadán I, Muñiz J, et al. Relationship between multimorbidity and outcomes in atrial fibrillation. Exp Gerontol. 2021;153:111482.
Proietti M, Lane DA, Lip GYH. Chronic kidney disease, time in therapeutic range and adverse clinical outcomes in anticoagulated patients with non-valvular atrial fibrillation: Observations from the SPORTIF Trials. EBioMedicine. 2016;8:309–16. DOI: 10.1016/j.ebiom.2016.04.013
Violi F, Davì G, Proietti M, Pastori D, Hiatt WR, Corazza GR, et al. Ankle-Brachial Index and cardiovascular events in atrial fibrillation: the ARAPACIS study. Thromb Haemost. 2016;115:856–63. DOI: 10.1160/TH15-07-0612
Romiti GF, Corica B, Pipitone E, Vitolo M, Raparelli V, Basili S, et al. Prevalence, management and impact of chronic obstructive pulmonary disease in atrial fibrillation: a systematic review and meta-Analysis of 4,200,000 patients. Eur Heart J. 2021;42:3541–3554C. DOI: 10.1093/eurheartj/ehab453
Alexander KP, Brouwer MA, Mulder H, Vinereanu D, Lopes RD, Proietti M, et al. Outcomes of apixaban versus warfarin in patients with atrial fibrillation and multi-morbidity: Insights from the ARISTOTLE trial. Am Heart J. 2019;208:123–31. DOI: 10.1016/j.ahj.2018.09.017
Lip GYH, Ntaios G. Novel clinical concepts in thrombosis: integrated care for stroke management-easy as ABC. Thromb Haemost. 2021. https://doi.org/10.1055/a-1632-1777.
Field M, Kuduvalli M, Torella F, McKay V, Khalatbari A, Lip GYH. Integrated care systems and the aortovascular hub. Thromb Haemost. 2021. https://doi.org/10.1055/a-1591-8033.
Burdett P, Lip GYH. Atrial fibrillation in the UK: predicting costs of an emerging epidemic recognizing and forecasting the cost drivers of atrial fibrillation-related costs. Eur Heart J - Qual Care Clin Outcomes. 2020. https://doi.org/10.1093/ehjqcco/qcaa093.
Yao Y, Guo Y, Lip GYH. The effects of implementing a mobile health-technology supported pathway on atrial fibrillation-related adverse events among patients with multimorbidity: the mAFA-II randomized clinical trial. JAMA Netw Open. 2021;4:2140071. DOI: 10.1001/jamanetworkopen.2021.40071
