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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
Objective The ‘Atrial fibrillation Better Care’ (ABC) pathway has been recently proposed as a holistic approach for the comprehensive management of patients with atrial fibrillation (AF). We performed a systematic review of current evidence for the use of the ABC pathway on clinical outcomes.
Methods and Results We performed a systematic review and meta-analysis according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed and EMBASE were searched for studies reporting the prevalence of ABC-pathway-adherent management in AF patients, and its impact on clinical outcomes (all-cause death, cardiovascular death, stroke, and major bleeding). Meta-analysis of odds ratio (OR) was performed with random-effects models; subgroup analysis and meta-regression were performed to account for heterogeneity. Among the eight studies included, we found a pooled prevalence of ABC-adherent management of 21% (95% confidence interval, CI: 13–34%), with a high grade of heterogeneity, explained by the increasing adherence to each ABC criterion. Patients treated according to the ABC pathway showed a lower risk of all-cause death (OR: 0.42; 95% CI: 0.31–0.56), cardiovascular death (OR: 0.37; 95% CI: 0.23–0.58), stroke (OR: 0.55; 95% CI: 0.37–0.82) and major bleeding (OR: 0.69; 95% CI: 0.51–0.94), with moderate heterogeneity. Prevalence of comorbidities was moderators of heterogeneity for all-cause and cardiovascular death, while longer follow-up was associated with increased effectiveness for all outcomes.
Conclusion Adherence to the ABC pathway was suboptimal, being adopted in one in every five patients. Adherence to the ABC pathway was associated with a reduction in the risk of major adverse outcomes.
* Joint senior authors.
Received: 26 April 2021
Accepted: 18 May 2021
21 May 2021 (online)
© 2021. Thieme. All rights reserved.
Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany
- 1 Proietti M, Lane DA, Boriani G, Lip GYH. Stroke prevention, evaluation of bleeding risk, and anticoagulant treatment management in atrial fibrillation contemporary international guidelines. Can J Cardiol 2019; 35 (05) 619-633
- 2 Boriani G, Proietti M, Laroche C. et al; EORP-AF Long-Term General Registry Investigators. 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 (07) 1013-1022
- 3 Dai H, Zhang Q, Much AA. et al. Global, regional, and national prevalence, incidence, mortality, and risk factors for atrial fibrillation, 1990-2017: results from the Global Burden of Disease Study 2017. Eur Heart J Qual Care Clin Outcomes 2020; (e-pub ahead of print). DOI: 10.1093/ehjqcco/qcaa061.
- 4 Singh SM, Abdel-Qadir H, Pang A. et al. Population trends in all-cause mortality and cause specific-death with incident atrial fibrillation. J Am Heart Assoc 2020; 9 (19) e016810
- 5 Proietti M, Marzona I, Vannini T. et al. Long-term relationship between atrial fibrillation, multimorbidity and oral anticoagulant drug use. Mayo Clin Proc 2019; 94 (12) 2427-2436
- 6 Alexander KP, Brouwer MA, Mulder H. et al; ARISTOTLE Investigators. Outcomes of apixaban versus warfarin in patients with atrial fibrillation and multi-morbidity: Insights from the ARISTOTLE trial. Am Heart J 2019; 208: 123-131
- 7 Kotecha D, Breithardt G, Camm AJ. et al. Integrating new approaches to atrial fibrillation management: the 6th AFNET/EHRA Consensus Conference. Europace 2018; 20 (03) 395-407
- 8 Kirchhof P. The future of atrial fibrillation management: integrated care and stratified therapy. Lancet 2017; 390 (10105): 1873-1887
- 9 Lip GYH. The ABC pathway: an integrated approach to improve AF management. Nat Rev Cardiol 2017; 14 (11) 627-628
- 10 Lip GYH, Banerjee A, Boriani G. et al. Antithrombotic therapy for atrial fibrillation: CHEST guideline and expert panel report. Chest 2018; 154 (05) 1121-1201
- 11 Joung B, Lee JM, Lee KH. et al; KHRS Atrial Fibrillation Guideline Working Group. 2018 Korean guideline of atrial fibrillation management. Korean Circ J 2018; 48 (12) 1033-1080
- 12 Hindricks G, Potpara T, Dagres N. et al; ESC Scientific Document Group. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021; 42 (05) 373-498
- 13 Stijnen T, Hamza TH, Özdemir P. Random effects meta-analysis of event outcome in the framework of the generalized linear mixed model with applications in sparse data. Stat Med 2010; 29 (29) 3046-3067
- 14 Knapp G, Hartung J. Improved tests for a random effects meta-regression with a single covariate. Stat Med 2003; 22 (17) 2693-2710
- 15 Harrer M, Cuijpers P, Furukawa TA. et al. Doing Meta-analysis in R: A Hands-on Guide. Erlangen: Prot Lab; 2019
- 16 Gumprecht J, Domek M, Proietti M. et al. Compliance of atrial fibrillation treatment with the Atrial fibrillation Better Care (ABC) pathway improves the clinical outcomes in the Middle East population: a report from the Gulf Survey of Atrial Fibrillation Events (SAFE) registry. J Clin Med 2020; 9 (05) 1286
- 17 Kozieł M, Simovic S, Pavlovic N. et al. Adherence to the ABC (Atrial fibrillation Better Care) pathway in the Balkan region: the BALKAN-AF survey. Pol Arch Intern Med 2020; 130 (03) 187-195
- 18 Pastori D, Menichelli D, Violi F. et al. The Atrial fibrillation Better Care (ABC) pathway and cardiac complications in atrial fibrillation: a potential sex-based difference. The ATHERO-AF study. Eur J Intern Med 2020; 85: 80-85
- 19 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 (11) 1359.e6-1366.e6
- 20 Proietti M, Lip GYH, Laroche C. et al; ESC-EORP Atrial Fibrillation General Long-Term Registry Investigators Group. 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 (02) 174-183
- 21 Proietti M, Vitolo M, Lip GYH. Integrated care and outcomes in patients with atrial fibrillation and comorbidities. Eur J Clin Invest 2021; 51 (06) e13498
- 22 Yang PS, Sung JH, Jang E. et al. Application of the simple atrial fibrillation better care pathway for integrated care management in frail patients with atrial fibrillation: a nationwide cohort study. J Arrhythm 2020; 36 (04) 668-677
- 23 Guo Y, Lane DA, Wang L. et al; mAF-App II Trial Investigators. Mobile health technology to improve care for patients with atrial fibrillation. J Am Coll Cardiol 2020; 75 (13) 1523-1534
- 24 Proietti M, Laroche C, Nieuwlaat R. et al; EORP-AF General Pilot Registry, Euro Heart Survey on AF Investigators. Increased burden of comorbidities and risk of cardiovascular death in atrial fibrillation patients in Europe over ten years: a comparison between EORP-AF pilot and EHS-AF registries. Eur J Intern Med 2018; 55: 28-34
- 25 Rahman F, Kwan GF, Benjamin EJ. Global epidemiology of atrial fibrillation. Nat Rev Cardiol 2014; 11 (11) 639-654
- 26 Burdett P, Lip GYH. Atrial fibrillation in the United Kingdom: predicting costs of an emerging epidemic recognising and forecasting the cost drivers of atrial fibrillation-related costs. Eur Heart J Qual Care Clin Outcomes 2020; DOI: 10.1093/ehjqcco/qcaa093.
- 27 Kirchhof P, Benussi S, Kotecha D. et al; ESC Scientific Document Group. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37 (38) 2893-2962
- 28 Rivera-Caravaca JM, Gil-Perez P, Lopez-García C. et al. A nurse-led atrial fibrillation clinic: impact on anticoagulation therapy and clinical outcomes. Int J Clin Pract 2020; 74 (12) e13634
- 29 LaRosa AR, Claxton J, O'Neal WT. et al. Association of household income and adverse outcomes in patients with atrial fibrillation. Heart 2020; 106 (21) 1679-1685
- 30 Guo Y, Guo J, Shi X. et al; mAF-App II Trial investigators. Mobile health technology-supported atrial fibrillation screening and integrated care: a report from the mAFA-II trial Long-term Extension Cohort. Eur J Intern Med 2020; 82: 105-111
- 31 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 (10) e014932
- 32 Yang P-S, Sung J-H, Jang E. et al. The effect of integrated care management on dementia in atrial fibrillation. J Clin Med 2020; 9 (06) 1696
- 33 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 (07) 856-861