The Atrial fibrillation Better Care (ABC) pathway is associated to a lower incidence of cardiac complications in patients with atrial fibrillation: a report from the ATHERO-AF study

Abstract

Abstract Background The integrated management of atrial fibrillation (AF) patients according to the Atrial fibrillation Better Care (ABC, A, Avoid stroke with anticoagulation; B, better symptom management; C, Cardiovascular and comorbidity risk management) pathway has associated with a reduced incidence of thromboembolic events and mortality. However, whether this approach also results in a lower rate of cardiac complications is unknown. Purpose To investigate the rate of major adverse cardiovascular events (MACE) in AF patients according to compliance with the ABC pathway. Methods This prospective single-center cohort study included 1157 patients with nonvalvular AF from the ATHERO-AF study. The A, B, and C groups were defined as follows: “A” by a Time in Therapeutic Range ≥70% in vitamin K antagonists-treated patients or appropriate dose for patients on direct oral anticoagulants; “B” by a European Heart Rhythm Association (EHRA) symptom scale I-II (vs. III-IV), and “C” as optimized cardiovascular comorbidity management (i.e. use of ACE inhibitors in heart failure patients, blood pressure <140/90, use of statins and beta blockers in patients with prior ischemic heart disease). The primary end point was a composite of MACE including fatal/non-fatal myocardial infarction, coronary revascularization and cardiovascular death (progressive heart failure, sudden cardiac death and procedure-related death). Results Overall, 458 (39.6%) patients were optimally managed according to the ABC (ABC-compliant group), while the remaining 729 patients presented at least one uncontrolled component (ABC non-compliant group). During a mean follow up of 35 months, (2688 patient-years), 64 MACE were recorded 2.38%/year. Kaplan Meier curve analysis showed a significant higher rate of MACE in ABC non-compliant group compared to the ABC-compliant (54 and 10 MACE in each group, respectively, log-rank test p=0.006, figure). The risk of MACE increased by the number of uncontrolled ABC components: Hazard ratio HR) for 1 component 1.697, 95% Confidence Interval 95% CI 0.814–3.537, p=0.158; HR for 2 components 4.157, 95% CI 1.994–8.665, p<0.001); HR for 3 components 5.100, 95% CI 1.596–16.295, p=0.006. ABC non-compliant group remained associated with an increased risk of MACE using Cox proportional hazard regression analysis (HR 2.175, 95% CI 1.098–4.309, p=0.026) after adjustment for CHA2DS2VASc score, antiplatelet drugs and digoxin use. Conclusion The majority of AF patients is not currently optimally managed. An integrated care ABC approach is associated with a reduced risk of MACE in the AF population. Figure 1. Kaplan-Meier curves Funding Acknowledgement Type of funding source: None