Effects of the Atrial fibrillation Better Care (ABC) pathway on outcomes among clinically complex chinese patients with atrial fibrillation with multimorbidity and polypharmacy
Authors: Stefil M , Kotalczyk A , Guo Y , Wang Y , Lip G 
Published: May 2022

Abstract

Funding Acknowledgements
Type of funding sources: None.

Introduction
Patients with atrial fibrillation (AF) commonly have complex clinical backgrounds. In this ancillary analysis we assessed the adherence to and the effectiveness of the Atrial fibrillation Better Care (ABC) pathway in reducing adverse outcomes in Chinese AF patients with a complex clinical background of multimorbidity and/or polypharmacy.

Methods
The ChiOTEAF registry[1] is a prospective, multicentre nationwide study conducted from October 2014 to December 2018. The primary outcomes of interest were the composite endpoint of all-cause death and thromboembolic (TE) events, as well as individual endpoints of all-cause death, TE events, and major bleeding. ’Multimorbidity’ was defined as the presence of ≥2 co-morbidities, ’polypharmacy’ was defined as the concomitant use of ≥5 medications. The participants were assessed against the ABC pathway criteria: patients qualified for the ‘A’ criterion (Avoid stroke) if they were treated with oral anticoagulants according to their TE risk; ‘B’ criterion (Better symptom control) if they demonstrated optimal symptom control defined as European Heart Rhythm Association score of I/II at baseline; ‘C’ criterion (Cardiovascular risk factor and Comorbidity optimisation) if they received disease-specific treatment(s) according to current guidelines at baseline. Patients were considered as ABC-adherent if they fulfilled all three criteria.

Results
The eligible cohort included 4644 patients with multimorbidity and 2262 patients with polypharmacy (Fig 1.), of whom 56.2% (mean age 74.4±10.2; 42.8% female) and 58.7% (mean age 74.6±10.1; 43.3% female) respectively had available data to assess the ABC pathway utilisation. Adherence to the ABC pathway was associated with lower odds ratio (OR) of the primary composite outcome in the multimorbidy (OR: 0.48; 95% CI: 0.29-0.79) and polypharmacy (OR: 0.39; 95% CI: 0.19-0.78) groups (Table 1.). Adherence to the ABC pathway was associated with a lower risk of all-cause death in multimorbid patients (OR: 0.51; 95% CI: 0.27-0.95) and TE events in patients with polypharmacy (OR: 0.31; 95% CI: 0.10-0.95). In a subgroup of patients with concomitant multimorbidity and polypharmacy the risk of composite outcome (OR: 0.38; 95% CI: 0.18-0.79) and TE events (OR: 0.31; 95% CI: 0.10-0.94) were lower in the ABC-adherent patients. There were no significant differences in the incidence of major bleeding among patients with multimorbidity, polypharmacy or both in the ABC-adherent compared to the non-ABC adherent groups. Health-related quality of life (QoF) was lower in the non-ABC adherent compared to the ABC-adherent patients.

Conclusion
This study shows that adherence to the ABC pathway is associated with improved clinical outcomes and QoF in Chinese AF patients with multimorbidity and/or polypharmacy. There is no evidence to suggest that adhering to the ABC pathway is associated with a higher risk of major bleeding events compared to standard practice.