Optimizing management of atrial fibrillation: integrated care, blood pressure control, ablation, and left atrial appendix occlusion.

Atrial fibrillation is the most common arrhythmia and increases in incidence and prevalence with age, with hypertension among other factors. While symptoms are usually mild, the major complication of atrial fibrillation is stroke. To avoid such a devastating complication, attempts are made to further improve care of such patients with anticoagulation, blood pressure control, and other measures. In their article ‘Integrated management of atrial fibrillation in primary care: results of the ALL-IN cluster randomized trial’, Carline Jo van den Dries and colleagues from the University Medical Center Utrecht in the Netherlands report the results of their cluster randomized, open-label, pragmatic non-inferiority trial in which 26 primary care practices were assigned to either integrated care or usual care. Integrated care consisted of (i) quarterly atrial fibrillation check-ups by trained nurses, focusing also on possibly interfering comorbidities; (ii) monitoring of anticoagulation; and finally (iii) easy access to consultations by cardiologists and anticoagulation clinics. The all-cause mortality rate was 3.5 per 100 patient-years in the intervention arm vs. 6.7 per 100 patient-years in the control arm, with an adjusted hazard ratio of 0.55, and a hazard ratio of 0.47 for non-cardiovascular mortality (Figure 1). Thus, in this cluster randomized trial, integrated care for elderly atrial fibrillation patients in primary care markedly reduces mortality compared with usual care, a provocative finding further discussed in an Editorial by Cecilia Linde from Karolinska Hospital in Stockholm, Sweden. Hypertensives are at particular risk of atrial fibrillation. Furthermore, in hypertensive patients, a J-shaped association between achieved systolic and diastolic blood pressure and cardiovascular events has been repeatedly described. Whether a similar association might exist with oral anticoagulation is unknown. In their article entitled ‘Cardiovascular outcomes, bleeding risk, and achieved blood pressure in patients on long-term anticoagulation with the thrombin antagonist dabigatran or warfarin: data from the RE-LY trial’, Michael Böhm and colleagues from the University Hospital in Homburg, Saarland, Germany report their subanalysis of the RELY trial that randomized 18 113 patients with atrial fibrillation. On-treatment systolic blood pressure (SBP) >140 mmHg and <120 mmHg was associated with allcause death compared with SBP 120–130 mmHg as a reference (Figure 2). For systemic embolization, risk was unchanged at SBP <110 mmHg, but increased between 140 and 160 mmHg with an adjusted hazard ratio of 1.81, and at >_160 mmHg with an adjusted hazard ratio of 3.35. Major bleedings were surprisingly increased at SBP <110 mmHg and at 110 to <120 mmHg, while there was no increased risk of major bleeding at SBP >130 mmHg. Similar patterns were observed for diastolic blood pressure with an increased risk at <70 mmHg with a hazard ratio of 1.55, and at >90 mmHg with a hazard ratio of 1.88 for all-cause death compared with 70 to <80 mmHg as a reference (Figure 2). Risk for any bleeding was increased at low diastolic blood pressure <70 mmHg with a hazard ratio of 1.46, and 1.13 at 80 to <90 mmHg, without increased risk at higher achieved values. Dabigatran 150 mg b.i. d. showed an advantage in all patients for all-cause death and systemic embolization, and there was an advantage for 110 mg dabigatran b.i. d. for major bleeding and any bleeding irrespective of achieved blood pressure. Similar results were obtained for baseline blood pressure, time-updated blood pressure, and blood pressure as a time-varying covariate. Thus, low achieved SBP is associated with increased risk of death, systemic embolization, and bleeding in patients with atrial fibrillation on oral anticoagulation,