Impact of Integrated Care Management on Clinical Outcomes in Atrial Fibrillation Patients: A Report From the FANTASIIA Registry

Background An integrated and holistic approach is increasingly advocated in patients with atrial fibrillation (AF), based on the “Atrial fibrillation Better Care (ABC) pathway: A, Avoid stroke with anticoagulation; B, better symptom management; C, cardiovascular and comorbidity risk management.” The aim of this study was to examine the prevalence of adherence to each component of the ABC pathway and to analyze its impact on long-term prognosis in the “real-world” cohort of AF patients from the FANTASIIA registry. Methods This prospective study included consecutive AF outpatients anticoagulated with direct oral anticoagulants (DOAC) or vitamin K antagonists (VKA) from June 2013 to October 2014. From the ABC pathway, adherence to the “A criterion” was defined by a time in the therapeutic range (TTR) ≥ 70% or correct dose with DOAC; “B criterion” adherence was defined by a European Heart Rhythm Association (EHRA) Symptom Scale I-II; and “C criterion” adherence was defined as optimized risk factors and comorbidity management. Baseline features and embolic events, severe bleeding, and all-cause and cardiovascular mortality rates up to 3 years of follow-up were analyzed, and a Cox multivariate analysis was performed to investigate the role of each component of the ABC pathway in predicting major events. Results A total of 1,955 AF patients (age: 74.4 ± 9.4 years; 43.2% female patients) were included in this study: adherence to A criterion was observed in 920 (47.1%) patients; adherence to B criterion was observed in 1,791 (91.6%) patients; and adherence to C criterion was observed in 682 (34.8%) patients. Only 394 (20.2%) of the whole population had good control of AF according to the ABC pathway. After a median follow-up of 1,078 days (IQR: 766–1,113), adherence to A criterion was independently associated with reduced cardiovascular mortality [HR: 0.67, 95%CI (0.45–0.99); p = 0.048] compared with non-adherence. Adherence to the B criterion was independently associated with reduced stroke [HR: 0.28, 95%CI (0.14–0.59); p < 0.001], all-cause mortality [HR: 0.49, 95%CI (0.35–0.69); p < 0.001], cardiovascular mortality [HR: 0.39, 95%CI (0.25–0.62); p < 0.001], and major adverse cardiovascular events (MACE) [HR: 0.41, 95%CI (0.28–0.62); p < 0.001] compared with non-adherence. AF patients with C criterion adherence had a significantly lower risk of myocardial infarction [HR: 0.31, 95%CI (0.15–0.66); p < 0.001]. Fully adherent ABC patients had a significant reduction in MACE [HR: 0.64, 95%CI (0.42–0.99); p = 0.042]. Conclusion In real-world anticoagulated AF patients from FANTASIIA registry, we observed a lack of adherence to integrated care management of AF following the ABC pathway. AF managed according to the ABC pathway was associated with a significant reduction in adverse outcomes during long follow-up, suggesting the benefit of a holistic and integrated approach to AF management.

[1]  G. Lip,et al.  “Novel Clinical Concepts in Thrombosis”: Integrated Care for Stroke Management—Easy as ABC , 2021, Thrombosis and Haemostasis.

[2]  G. Lip,et al.  Integrated Care Systems and the Aortovascular Hub , 2021, Thrombosis and Haemostasis.

[3]  G. Lip,et al.  The Atrial Fibrillation Better Care pathway for managing atrial fibrillation: a review , 2021, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology.

[4]  A. Camm,et al.  2021 European Heart Rhythm Association Practical Guide on the Use of Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation. , 2021, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology.

[5]  I. Welters,et al.  A Systematic Review of Anticoagulation Strategies for Patients with Atrial Fibrillation in Critical Care , 2021, Thrombosis and Haemostasis.

[6]  S. Kitchen,et al.  2021 Update of the International Council for Standardization in Haematology Recommendations for Laboratory Measurement of Direct Oral Anticoagulants , 2021, Thrombosis and Haemostasis.

[7]  G. Lip,et al.  Atrial Fibrillation in the United Kingdom: Predicting Costs of an Emerging Epidemic Recognising and Forecasting the Cost Drivers of Atrial Fibrillation-related costs. , 2020, European heart journal. Quality of care & clinical outcomes.

[8]  F. Violi,et al.  The Atrial fibrillation Better Care (ABC) pathway and cardiac complications in atrial fibrillation: a potential sex-based difference. The ATHERO-AF study. , 2020, European journal of internal medicine.

[9]  T. Potpara,et al.  Self-reported treatment burden in patients with atrial fibrillation: quantification, major determinants, and implications for integrated holistic management of the arrhythmia. , 2020, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology.

[10]  G. Boriani,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. , 2020, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology.

[11]  Evi X. Stavrou,et al.  Monitoring DOACs with a Novel Dielectric Microsensor: A Clinical Study , 2020, Thrombosis and Haemostasis.

[12]  Jeroen J. Bax,et al.  2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS). , 2020, European heart journal.

[13]  D. Conen,et al.  Health-related quality of life in patients with atrial fibrillation: The role of symptoms, comorbidities, and the type of atrial fibrillation , 2019, PloS one.

[14]  P. Verhamme,et al.  Accuracy of a Rapid Diagnostic Test for the Presence of Direct Oral Factor Xa or Thrombin Inhibitors in Urine—A Multicenter Trial , 2019, Thrombosis and Haemostasis.

[15]  C. Nam,et al.  NOAC Adherence of Patients with Atrial Fibrillation in the Real World: Dosing Frequency Matters? , 2019, Thrombosis and Haemostasis.

[16]  S. Sandberg,et al.  Quality of Warfarin Therapy and Quality of Life are Improved by Self-Management for Two Years , 2019, Thrombosis and Haemostasis.

[17]  G. Lip,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 , 2019, Thrombosis and Haemostasis.

[18]  F. Violi,et al.  Integrated Care Management of Patients With Atrial Fibrillation and Risk of Cardiovascular Events: The ABC (Atrial fibrillation Better Care) Pathway in the ATHERO-AF Study Cohort. , 2019, Mayo Clinic proceedings.

[19]  M. Michal,et al.  Subtherapeutic Anticoagulation Control under Treatment with Vitamin K-Antagonists—Data from a Specialized Coagulation Service , 2019, Thrombosis and Haemostasis.

[20]  K. Jolly,et al.  Improving the Prescription of Oral Anticoagulants in Atrial Fibrillation: A Systematic Review , 2019, Thrombosis and Haemostasis.

[21]  M. Martín-Pérez,et al.  Predictors of Over-Anticoagulation in Warfarin Users in the UK General Population: A Nested Case–Control Study in a Primary Health Care Database , 2018, Thrombosis and Haemostasis.

[22]  G. Lip,et al.  Improved Outcomes by Integrated Care of Anticoagulated Patients with Atrial Fibrillation Using the Simple ABC (Atrial Fibrillation Better Care) Pathway. , 2018, American Journal of Medicine.

[23]  M. Murad,et al.  Treatment burden should be included in clinical practice guidelines , 2018, British Medical Journal.

[24]  A. Bayés‐Genís,et al.  Inappropriate doses of direct oral anticoagulants in real-world clinical practice: prevalence and associated factors. A subanalysis of the FANTASIIA Registry , 2018, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology.

[25]  G. Lip,et al.  Quality of oral anticoagulation with vitamin K antagonists in ‘real-world’ patients with atrial fibrillation: a report from the prospective multicentre FANTASIIA registry , 2018, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology.

[26]  A. Camm,et al.  The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation: executive summary. , 2018, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology.

[27]  G. Lip,et al.  Innovative strategies to improve adherence to non-vitamin K antagonist oral anticoagulants for stroke prevention in atrial fibrillation , 2018, European heart journal.

[28]  A. Camm,et al.  The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. , 2018, European heart journal.

[29]  G. Hindricks,et al.  2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). , 2018, European heart journal.

[30]  E. Mohammadi,et al.  Barriers and facilitators related to the implementation of a physiological track and trigger system: A systematic review of the qualitative evidence , 2017, International journal for quality in health care : journal of the International Society for Quality in Health Care.

[31]  G. Lip.  The ABC pathway: an integrated approach to improve AF management , 2017, Nature Reviews Cardiology.

[32]  Christopher X. Wong,et al.  Integrated care in atrial fibrillation: a systematic review and meta-analysis , 2017, Heart.

[33]  G. Lip,et al.  Patients' experiences of atrial fibrillation and non-vitamin K antagonist oral anticoagulants (NOACs), and their educational needs: A qualitative study. , 2017, Thrombosis research.

[34]  L. Fauchier,et al.  Causes of Death and Influencing Factors in Patients with Atrial Fibrillation. , 2016, The American journal of medicine.

[35]  M. Hsieh,et al.  A nationwide cohort study , 2016 .

[36]  B. Gersh,et al.  Association Between Atrial Fibrillation Symptoms, Quality of Life, and Patient Outcomes: Results From the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) , 2015, Circulation. Cardiovascular quality and outcomes.

[37]  Á. Cequier,et al.  Quality of Anticoagulation With Vitamin K Antagonists , 2015, Clinical cardiology.

[38]  P. Kirchhof,et al.  The European Heart Rhythm Association symptom classification for atrial fibrillation: validation and improvement through a simple modification , 2014, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology.

[39]  Phyllis Zatlin.  As Easy as ABC , 2013 .

[40]  S. Mody,et al.  Burden of comorbidities among patients with atrial fibrillation , 2013, Therapeutic advances in cardiovascular disease.

[41]  Gerhard Hindricks,et al.  2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation--developed with the special contribution of the European Heart Rhythm Association. , 2012, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology.

[42]  Jeroen J. Bax,et al.  2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. , 2012, European heart journal.

[43]  Gregory Y H Lip,et al.  A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. , 2010, Chest.

[44]  S. Michie,et al.  Assessing the effectiveness and cost effectiveness of adaptive e-Learning to improve dietary behaviour: protocol for a systematic review , 2010, BMC public health.

[45]  Gregory Y H Lip,et al.  Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. , 2010, Chest.

[46]  Massimo Santini,et al.  Prognosis, disease progression, and treatment of atrial fibrillation patients during 1 year: follow-up of the Euro Heart Survey on atrial fibrillation. , 2008, European heart journal.

[47]  M. Aguilar,et al.  Meta-analysis: Antithrombotic Therapy to Prevent Stroke in Patients Who Have Nonvalvular Atrial Fibrillation , 2007, Annals of Internal Medicine.

[48]  M. Rich,et al.  Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. , 2001, JAMA.

[49]  E. Vermeire,et al.  Patient adherence to treatment: three decades of research. A comprehensive review , 2001, Journal of clinical pharmacy and therapeutics.

[50]  Martha J. Radford,et al.  Validation of Clinical Classification Schemes for Predicting Stroke: Results From the National Registry of Atrial Fibrillation , 2001 .

[51]  J. Jost,et al.  Executive Summary , 1998, OECD Reviews of Pension Systems: Peru.

[52]  Brian T. Austin,et al.  Organizing care for patients with chronic illness. , 1996, The Milbank quarterly.

[53]  G. Lip,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 , 2021, Thrombosis and Haemostasis.

[54]  D. Zenkert,et al.  Functional Composites and Structures , 2019 .

[55]  P. Cardon,et al.  A qualitative study. , 2001 .

[56]  L. V. van Loon,et al.  CLINICAL STUDY The , 2022 .