Thromb Haemost 2019; 119(10): 1695-1703
DOI: 10.1055/s-0039-1693516
Stroke, Systemic or Venous Thromboembolism
Georg Thieme Verlag KG Stuttgart · New York

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

Minjae Yoon*
1   Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
,
Pil-Sung Yang*
2   Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
,
Eunsun Jang
1   Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
,
Hee Tae Yu
1   Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
,
Tae-Hoon Kim
1   Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
,
Jae-Sun Uhm
1   Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
,
Jong-Youn Kim
1   Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
,
Jung-Hoon Sung
2   Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
,
Hui-Nam Pak
1   Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
,
Moon-Hyoung Lee
1   Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
,
Boyoung Joung**
1   Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
,
1   Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
3   Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, United Kingdom
› Institutsangaben
Funding This study was supported by a research grant from the Basic Science Research Program through the National Research Foundation of Korea funded by the Ministry of Education, Science, and Technology (NRF-2017R1A2B3003303) and grants from the Korean Healthcare Technology R&D project funded by the Ministry of Health & Welfare (HI16C0058, HI15C1200).
Weitere Informationen

Publikationsverlauf

29. Mai 2019

12. Juni 2019

Publikationsdatum:
02. Juli 2019 (online)

Abstract

Background An integrated care approach might be of benefit for clinical outcomes of patients with atrial fibrillation (AF). This study evaluated whether compliance with the Atrial fibrillation Better Care (ABC) pathway for integrated care management (“A” Avoid stroke; “B” Better symptom management; “C” Cardiovascular risk and Comorbidity optimization) would improve population-based clinical outcomes in a nationwide AF cohort.

Methods and Results From the Korea National Health Insurance Service database, a total of 204,842 nonvalvular AF patients were enrolled between January 1, 2005 and December 31, 2015. Patients that fulfilled all criteria of the ABC pathway were defined as the “ABC” group, and those who did not were the “Non-ABC” group.

Over a mean follow-up of 6.2 ± 3.5 years, the ABC pathway compliant group had lower rates of all-cause death (0.80 vs. 2.72 per 100 person-years, p < 0.001) and the composite outcome of “death, ischemic stroke, major bleeding, and myocardial infarction” (2.34 vs. 5.92 per 100 person-years, p < 0.001) compared with the Non-ABC compliant group. Adjusted Cox multivariable regression showed that the ABC group had a significantly lower risk of all-cause death (adjusted hazard ratio [HR] 0.82; 95% confidence interval [CI], 0.78–0.86) and the composite outcome (adjusted HR 0.86; 95% CI, 0.83–0.89). With the increasing numbers of ABC pathway criteria fulfilled, the risk of all-cause death and composite outcome were progressively lowered.

Conclusion In the first study of a nationwide population cohort, we show that compliance with the simple ABC pathway is associated with improved clinically relevant outcomes of patients with AF. Given the high health care burden associated with AF, such a streamlined holistic approach to AF management should be implemented, to improve the care of such patients.

* The first two authors contributed equally to this work.


** Joint senior authors.


Note: The review process for this paper was fully handled by Christian Weber, Editor-in-Chief.


Supplementary Material

 
  • References

  • 1 Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke 1991; 22 (08) 983-988
  • 2 Wolf PA, Mitchell JB, Baker CS, Kannel WB, D'Agostino RB. Impact of atrial fibrillation on mortality, stroke, and medical costs. Arch Intern Med 1998; 158 (03) 229-234
  • 3 Kim TH, Yang PS, Uhm JS. , et al. CHA2DS2-VASc score (congestive heart failure, hypertension, age ≥75 [doubled], diabetes mellitus, prior stroke or transient ischemic attack [doubled], vascular disease, age 65-74, female) for stroke in Asian patients with atrial fibrillation: a Korean nationwide sample cohort study. Stroke 2017; 48 (06) 1524-1530
  • 4 Kim D, Yang PS, Jang E. , et al. 10-year nationwide trends of the incidence, prevalence, and adverse outcomes of non-valvular atrial fibrillation nationwide health insurance data covering the entire Korean population. Am Heart J 2018; 202: 20-26
  • 5 Kim D, Yang PS, Jang E. , et al. Increasing trends in hospital care burden of atrial fibrillation in Korea, 2006 through 2015. Heart 2018; 104 (24) 2010-2017
  • 6 Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med 2007; 146 (12) 857-867
  • 7 Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA 2001; 285 (22) 2864-2870
  • 8 Gómez-Outes A, Lagunar-Ruíz J, Terleira-Fernández AI, Calvo-Rojas G, Suárez-Gea ML, Vargas-Castrillón E. Causes of death in anticoagulated patients with atrial fibrillation. J Am Coll Cardiol 2016; 68 (23) 2508-2521
  • 9 Fauchier L, Villejoubert O, Clementy N. , et al. Causes of death and influencing factors in patients with atrial fibrillation. Am J Med 2016; 129 (12) 1278-1287
  • 10 Kirchhof P. The future of atrial fibrillation management: integrated care and stratified therapy. Lancet 2017; 390 (10105): 1873-1887
  • 11 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
  • 12 Gallagher C, Elliott AD, Wong CX. , et al. Integrated care in atrial fibrillation: a systematic review and meta-analysis. Heart 2017; 103 (24) 1947-1953
  • 13 Lip GYH. The ABC pathway: an integrated approach to improve AF management. Nat Rev Cardiol 2017; 14 (11) 627-628
  • 14 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) 1359-1366
  • 15 Pastori D, Pignatelli P, Menichelli D, Violi F, Lip GYH. 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. Mayo Clin Proc 2018; pii: S0025-6196(18)30891-7
  • 16 Lee YH, Han K, Ko SH, Ko KS, Lee KU. ; Taskforce Team of Diabetes Fact Sheet of the Korean Diabetes Association. Data analytic process of a nationwide population-based study using national health information database established by National Health Insurance Service. Diabetes Metab J 2016; 40 (01) 79-82
  • 17 Kim D, Yang PS, Kim TH. , et al. Ideal blood pressure in patients with atrial fibrillation. J Am Coll Cardiol 2018; 72 (11) 1233-1245
  • 18 Kim TH, Yang PS, Kim D. , et al. CHA2DS2-VASc score for identifying truly low-risk atrial fibrillation for stroke: a Korean Nationwide Cohort Study. Stroke 2017; 48 (11) 2984-2990
  • 19 Wan Y, Heneghan C, Perera R. , et al. Anticoagulation control and prediction of adverse events in patients with atrial fibrillation: a systematic review. Circ Cardiovasc Qual Outcomes 2008; 1 (02) 84-91
  • 20 Gallagher AM, Setakis E, Plumb JM, Clemens A, van Staa TP. Risks of stroke and mortality associated with suboptimal anticoagulation in atrial fibrillation patients. Thromb Haemost 2011; 106 (05) 968-977
  • 21 Kooistra HA, Veeger NJ, Khorsand N, Kluin-Nelemans HC, Meijer K, Piersma-Wichers M. Long-term quality of VKA treatment and clinical outcome after extreme overanticoagulation in 14,777 AF and VTE patients. Thromb Haemost 2015; 113 (04) 881-890
  • 22 Singer DE, Hellkamp AS, Piccini JP. , et al; ROCKET AF Investigators. Impact of global geographic region on time in therapeutic range on warfarin anticoagulant therapy: data from the ROCKET AF clinical trial. J Am Heart Assoc 2013; 2 (01) e000067
  • 23 Shimada YJ, Yamashita T, Koretsune Y. , et al. Effects of regional differences in Asia on efficacy and safety of edoxaban compared with warfarin--insights from the ENGAGE AF-TIMI 48 trial. Circ J 2015; 79 (12) 2560-2567
  • 24 Mazurek M, Huisman MV, Rothman KJ. , et al; GLORIA-AF Investigators. Regional differences in antithrombotic treatment for atrial fibrillation: insights from the GLORIA-AF Phase II Registry. Thromb Haemost 2017; 117 (12) 2376-2388
  • 25 Raparelli V, Proietti M, Cangemi R, Lip GY, Lane DA, Basili S. Adherence to oral anticoagulant therapy in patients with atrial fibrillation. Focus on non-vitamin K antagonist oral anticoagulants. Thromb Haemost 2017; 117 (02) 209-218
  • 26 Caldeira D, David C, Sampaio C. Rate versus rhythm control in atrial fibrillation and clinical outcomes: updated systematic review and meta-analysis of randomized controlled trials. Arch Cardiovasc Dis 2012; 105 (04) 226-238
  • 27 Boriani G, Laroche C, Diemberger I. , et al. Asymptomatic atrial fibrillation: clinical correlates, management, and outcomes in the EORP-AF Pilot General Registry. Am J Med 2015; 128 (05) 509-518
  • 28 Pokorney SD, Piccini JP, Stevens SR. , et al; ROCKET AF Steering Committee & Investigators; ROCKET AF Steering Committee Investigators. Cause of death and predictors of all-cause mortality in anticoagulated patients with nonvalvular atrial fibrillation: data from ROCKET AF. J Am Heart Assoc 2016; 5 (03) e002197
  • 29 Marijon E, Le Heuzey JY, Connolly S. , et al; RE-LY Investigators. Causes of death and influencing factors in patients with atrial fibrillation: a competing-risk analysis from the randomized evaluation of long-term anticoagulant therapy study. Circulation 2013; 128 (20) 2192-2201
  • 30 Boriani G, Proietti M. Atrial fibrillation prevention: an appraisal of current evidence. Heart 2018; 104 (11) 882-887
  • 31 Baek YS, Yang PS, Kim TH. , et al. Associations of abdominal obesity and new-onset atrial fibrillation in the general population. J Am Heart Assoc 2017; 6 (06) 6
  • 32 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
  • 33 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
  • 34 Yao X, Abraham NS, Alexander GC. , et al. Effect of adherence to oral anticoagulants on risk of stroke and major bleeding among patients with atrial fibrillation. J Am Heart Assoc 2016; 5 (02) 5
  • 35 Yao X, Abraham NS, Sangaralingham LR. , et al. Effectiveness and safety of dabigatran, rivaroxaban, and apixaban versus warfarin in nonvalvular atrial fibrillation. J Am Heart Assoc 2016; 5 (06) 5