Use of the Atrial Fibrillation Better Care Pathway in Real-World Patients

The Atrial Fibrillation Better Care (ABC) pathway has been proposed for atrial fibrillation (AF) management. After reviewing patients with AF in the FANTASIIA registry, María Asunción Esteve-Pasto and collaborating researchers reported “a lack of adherence to integrated care management of AF following the ABC pathway.” They also noted that “AF managed according to the ABC pathway was associated with a significant reduction in adverse outcomes during long follow-up, suggesting the benefit of a holistic and integrated approach to AF management.”

The findings were published in Frontiers in Cardiovascular Medicine.

Esteve-Pasto and colleagues defined the ABC pathway as, “A, Avoid stroke with anticoagulation; B, better symptom management; C, cardiovascular and comorbidity risk management.”

The study included 1,955 patients with AF who were receiving direct oral anticoagulants (DOAC) or vitamin K antagonists (VKA) between June 2013 and October 2014. To evaluate adherence to the ABC pathway, the authors defined “A criterion” as time in therapeutic range (TTR) of ≥70% or correct DOAC dose; “B criterion” as European Hearty Rhythm Association (EHRA) Symptom Scale I–II; and “C criterion” as optimal management of risk and comorbidity factors. The authors additionally assessed the value of the three ABC pathway components for predicting major adverse events.

Among the overall cohort, the researchers observed adherence to the A, B, and C criterion in 920 (47.1%), 1,791 (91.6%), and 682 (34.8%) patients, respectively. According to the authors, only 20.2% of patients had “good control of AF according to the ABC pathway.”

Compared with non-adherence, A criterion adherence was independently associated with reduced cardiovascular mortality (hazard ratio [HR] = 0.67; 95% confidence interval [CI], 0.45–0.99; p = 0.048), and B criterion adherence was independently associated with:

  • Reduced stroke (HR = 0.28; 95% CI, 0.14–0.59; p <0.001)
  • All-cause mortality (HR = 0.49; 95% CI, 0.35–0.69; p <0.001)
  • Cardiovascular mortality (HR = 0.39; 95% CI, 0.25–0.62); p <0.001)
  • Major adverse cardiovascular events (HR = 0.41; 95% CI 0.28–0.62; p <0.001)

Finally, C criterion adherence was associated with significantly lower risk of myocardial infarction (HR = 0.31; 95% CI, 0.15–0.66; p <0.001). Patients who were fully adherent to ABC had a significant reduction in major adverse cardiovascular events (HR = 0.64; 95% CI, 0.42–0.99; p = 0.042).

In summary, Esteve-Pasto and colleagues wrote, “Our study is one of the few based on a prospective cohort and provides more evidence for the use of ABC pathway as the integrated management of AF patients (both under VKA and DOAC), also highlighting the importance of the symptom management.”