The Year in Cardiovascularmedicine 2020: Arrhythmias

Harry J.G.M. Crijns; Frits Prinzen; Pier D. Lambiase; Prashanthan Sanders; Josep Brugada


Eur Heart J. 2021;42(5):499-507. 

In This Article

Randomized Trials on Integrated Care in Atrial Fibrillation

Interesting randomized trials on integrated AF management included the ALL-IN trial, a cluster randomized trial in elderly AF patients in primary care, which showed that integrated care delivered by practice nurses supervised by general practitioners reduced all-cause mortality by 45% compared to usual-care.[3] This is impressive and highlights the power of 'simple' interventions if deployed systematically. The integrated care pathway included quarterly AF check-ups by the practice nurse, case management of antithrombotic treatment, and easy-access consultation of a cardiologist. This represents patient-centered shared responsibilities between primary care, anticoagulation clinics, cardiologists, and patients. Similarly, RACE 4 reported that nurse-led, information and communication technology (ICT)-supported, and physician-supervised integrated care reduces morbidity and mortality in experienced centres but not in less-experienced centres and emphasized the importance of training in an integrated environment.[4] Key elements of integrated care in these trials were the multidisciplinary team approach, education, and empowerment of patients and where possible application of decision support technology.

Recent mHealth solutions include TeleCheck-AF[5,6] and a mobile AF application incorporating the ABC pathway (Figure 1).[7] The mAFA II trial reported a significant reduction in all-cause death and adverse cardiovascular events compared to routine management in high-risk AF.[7] Notably, single elements of integrated care such as application of a clinical decision support system,[8] an educational[9] or a motivational[10] intervention to improve anticoagulation or introduction of shared decision-making[11] improve the level of care but not prognosis.

In integrated care, patient-driven life-style changes targeting obesity, alcohol, and blood pressure control is important before performing rhythm control with catheter ablation. In a large cohort of 402 406 individuals from the UK Biobank, regular physical activity was related with a lower incidence of AF (especially in women) and ventricular arrhythmias but not of bradyarrhythmias.[12] Also, a randomized trial provided proof-of-concept data to support alcohol cessation as secondary prophylaxis against AF in regular drinkers.[13] Per nature of the trial, it focused on one element of life style whilst a more comprehensive multi-level modification of AF risk factors may be needed to abrogate risks of AF in daily life.[14]