Mobile health applications for managing atrial fibrillation for healthcare professionals and patients: a systematic review

Patients perspectives on integrating eHealth in regular care pathways for atrial fibrillation: evaluating photoplethysmography for remote self-assessment

AIMS

Smartphone applications for heart rate and rhythm assessment are increasingly used for the management of atrial fibrillation (AF). Although the use of a photoplethysmography (PPG)-based smartphone application with subsequent (tele)consultations for AF management has been proven feasible in the TeleCheck-AF project, specific needs, and expectations of patients with AF are unclear. The aim of this study is to evaluate patients' perspectives on the use of remote PPG-based electronical health (eHealth) integrated in regular care pathways for AF.

METHODS AND RESULTS

A qualitative study was conducted among patients with known AF, who have used a PPG-based smartphone application around scheduled (tele)consultations. Semi-structured interviews were audio-recorded and transcribed verbatim. Data were analysed according to conventional content analysis.In total, 14 patients were interviewed. Five main themes were defined after analysis, i.e. smartphone application usability, requirements for eHealth implementation, remote self-assessment, patient engagement, and blended care (i.e. combining digital and face-to-face care). Overall, the participants were positive about the use of the PPG-based smartphone application and subsequent (tele)consultation. Using this application made the participants feel involved and led to active participation. In addition, the healthcare provider-patient relationship appeared an important aspect for adequate implementation. Particularly, timely consultation was found important, to discuss the results with their healthcare provider.

CONCLUSION

The results of this study emphasize the importance of blended care for the implementation of remote PPG-based eHealth in AF management. The use of a PPG-based smartphone application in regular care can support patient engagement and subsequently the process of shared decision making.

Future Patient-Telerehabilitation of Patients With Atrial Fibrillation: Protocol for a Multicenter, Mixed Methods, Randomized Controlled Trial

BACKGROUND

Atrial fibrillation (AF) is a chronic cardiovascular condition with a lifetime risk of 1 in 3 and a prevalence of 3% among adults. AF's prevalence is predicted to more than double during the next 20 years due to better detection, increasing comorbidities, and an aging population. Due to increased AF prevalence, telerehabilitation has been developed to enhance patient engagement, health care accessibility, and compliance through digital technologies. A telerehabilitation program called "Future Patient-telerehabilitation of patients with AF (FP-AF)" has been developed to enhance rehabilitation for AF. The FP-AF program comprises two modules: (1) an education and monitoring module using telerehabilitation technologies (4 months) and (2) a follow-up module, where patients can measure steps and access a data and knowledge-sharing portal, HeartPortal, using their digital devices. Those patients in the FP-AF program measure their heart rhythm, pulse, blood pressure, weight, steps, and sleep. Patients also complete web-based questionnaires regarding their well-being and coping with AF. All recorded data are transmitted to the HeartPortal, accessible to patients, relatives, and health care professionals.

OBJECTIVE

This paper aims to describe the research design, outcome measures, and data collection techniques in a clinical trial of the FP-AF program for patients with AF.

METHODS

This is a multicenter, mixed methods, randomized controlled trial. Patients are recruited from AF clinics serving the North Jutland region of Denmark. The telerehabilitation group will participate in the FP-AF program, while the control group will follow the conventional care regime based on physical visits to the AF clinic. The primary outcome measure is AF-specific health-related quality of life, to be assessed using the Atrial Fibrillation Effect on Quality-of-Life Questionnaire. Secondary outcomes are knowledge of AF; measurement of vital parameters; level of anxiety and depression; degree of motivation; burden of AF; use of the HeartPortal; qualitative exploration of patients', relatives', and health care professionals' experiences of participating in the FP-AF program; cost-effectiveness evaluation of the program; and analysis of multiparametric monitoring data. Outcomes are assessed through data from digital technologies, interviews, and questionnaires.

RESULTS

Patient enrollment began in January 2023 and will be completed by December 2024, with a total of 208 patients enrolled. Qualitative interviews conducted in spring 2024 will be analyzed and published in peer-reviewed journals in 2025. Data from questionnaires and digital technologies will be analyzed upon study completion and presented at international conferences and published in peer-reviewed journals by the fall of 2025.

CONCLUSIONS

Results from the FP-AF study will determine whether the FP-AF program can increase quality of life for patients with AF and increase their knowledge of symptoms and living with AF in everyday life compared to conventional AF care. The cost-effectiveness evaluation will determine whether telerehabilitation can be a viable alternative for rehabilitation of patients with AF.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06101485; https://clinicaltrials.gov/study/NCT06101485.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/64259.

Use of digital patient decision-support tools for atrial fibrillation treatments: a systematic review and meta-analysis

OBJECTIVES

To assess the effects of digital patient decision-support tools for atrial fibrillation (AF) treatment decisions in adults with AF.

STUDY DESIGN

Systematic review and meta-analysis.

ELIGIBILITY CRITERIA

Eligible randomised controlled trials (RCTs) evaluated digital patient decision-support tools for AF treatment decisions in adults with AF.

INFORMATION SOURCES

We searched MEDLINE, EMBASE and Scopus from 2005 to 2023.Risk-of-bias (RoB) assessment: We assessed RoB using the Cochrane Risk of Bias Tool 2 for RCTs and cluster RCT and the ROBINS-I tool for quasi-experimental studies.

SYNTHESIS OF RESULTS

We used random effects meta-analysis to synthesise decisional conflict and patient knowledge outcomes reported in RCTs. We performed narrative synthesis for all outcomes. The main outcomes of interest were decisional conflict and patient knowledge.

RESULTS

13 articles, reporting on 11 studies (4 RCTs, 1 cluster RCT and 6 quasi-experimental) met the inclusion criteria. There were 2714 participants across all studies (2372 in RCTs), of which 26% were women and the mean age was 71 years. Socioeconomically disadvantaged groups were poorly represented in the included studies. Seven studies (n=2508) focused on non-valvular AF and the mean CHAD2DS2-VASc across studies was 3.2 and for HAS-BLED 1.9. All tools focused on decisions regarding thromboembolic stroke prevention and most enabled calculation of individualised stroke risk. Tools were heterogeneous in features and functions; four tools were patient decision aids. The readability of content was reported in one study. Meta-analyses showed a reduction in decisional conflict (4 RCTs (n=2167); standardised mean difference -0.19; 95% CI -0.30 to -0.08; p=0.001; I2=26.5%; moderate certainty evidence) corresponding to a decrease in 12.4 units on a scale of 0 to 100 (95% CI -19.5 to -5.2) and improvement in patient knowledge (2 RCTs (n=1057); risk difference 0.72, 95% CI 0.68, 0.76, p<0.001; I2=0%; low certainty evidence) favouring digital patient decision-support tools compared with usual care. Four of the 11 tools were publicly available and 3 had been implemented in healthcare delivery.

CONCLUSIONS

In the context of stroke prevention in AF, digital patient decision-support tools likely reduce decisional conflict and may result in little to no change in patient knowledge, compared with usual care. Future studies should leverage digital capabilities for increased personalisation and interactivity of the tools, with better consideration of health literacy and equity aspects. Additional robust trials and implementation studies are warranted.

PROSPERO REGISTRATION NUMBER

CRD42020218025.

Education of Patients With Atrial Fibrillation and Evaluation of the Efficacy of a Mobile Virtual Patient Environment: Protocol for a Multicenter Pseudorandomized Controlled Trial

BACKGROUND

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and is a leading cause of mortality and morbidity. Patient knowledge about AF and its management is paramount but often limited. Patients need to be appropriately informed about treatment options, medicinal adherence, and potential consequences of nonadherence, while also understanding treatment goals and expectations from it. Mobile health apps have experienced an explosion both in their availability and acceptance as "soft interventions" for patient engagement and education; however, the prolific nature of such solutions revealed a gap in the evidence base regarding their efficacy and impact. Virtual patients (VPs), interactive computer simulations, have been used as learning activities in modern health care education. VPs demonstrably improved cognitive and behavioral skills; hence, they have been effectively implemented across undergraduate and postgraduate curricula. However, their application in patient education has been rather limited so far.

OBJECTIVE

This work aims to implement and evaluate the efficacy of a mobile-deployed VP regimen for the education and engagement of patients with AF on crucial topics regarding their condition. A mobile VP app is being developed with the goal of each VP being a simple scenario with a set goal and very specific messages and will be subsequently attempted and evaluated.

METHODS

A mobile VP player app is being developed so as to be used for the design of 3 educational scenarios for AF management. A pseudorandomized controlled trial for the efficacy of VPs is planned to be executed at 3 sites in Greece, Ukraine, and Kazakhstan for patients with AF. The Welch t test will be used to demonstrate the performance of patients' evaluation of the VP experience.

RESULTS

Our study is at the development stage. A preliminary study regarding the system's development and feasibility was initiated in December 2022. The results of our study are expected to be available in 2024 or when the needed sample size is achieved.

CONCLUSIONS

This study aims to evaluate and demonstrate the first significant evidence for the value of VP resources in outreach and training endeavors for empowering and patients with AF and fostering healthy habits among them.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/45946.

The digital journey: 25 years of digital development in electrophysiology from an Europace perspective

AIMS

Over the past 25 years there has been a substantial development in the field of digital electrophysiology (EP) and in parallel a substantial increase in publications on digital cardiology.In this celebratory paper, we provide an overview of the digital field by highlighting publications from the field focusing on the EP Europace journal.

RESULTS

In this journey across the past quarter of a century we follow the development of digital tools commonly used in the clinic spanning from the initiation of digital clinics through the early days of telemonitoring, to wearables, mobile applications, and the use of fully virtual clinics. We then provide a chronicle of the field of artificial intelligence, a regulatory perspective, and at the end of our journey provide a future outlook for digital EP.

CONCLUSION

Over the past 25 years Europace has published a substantial number of papers on digital EP, with a marked expansion in digital publications in recent years.

EHRA expert consensus document on the management of arrhythmias in frailty syndrome, endorsed by the Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA)

There is an increasing proportion of the general population surviving to old age with significant chronic disease, multi-morbidity, and disability. The prevalence of pre-frail state and frailty syndrome increases exponentially with advancing age and is associated with greater morbidity, disability, hospitalization, institutionalization, mortality, and health care resource use. Frailty represents a global problem, making early identification, evaluation, and treatment to prevent the cascade of events leading from functional decline to disability and death, one of the challenges of geriatric and general medicine. Cardiac arrhythmias are common in advancing age, chronic illness, and frailty and include a broad spectrum of rhythm and conduction abnormalities. However, no systematic studies or recommendations on the management of arrhythmias are available specifically for the elderly and frail population, and the uptake of many effective antiarrhythmic therapies in these patients remains the slowest. This European Heart Rhythm Association (EHRA) consensus document focuses on the biology of frailty, common comorbidities, and methods of assessing frailty, in respect to a specific issue of arrhythmias and conduction disease, provide evidence base advice on the management of arrhythmias in patients with frailty syndrome, and identifies knowledge gaps and directions for future research.

Pharmacist management of atrial fibrillation in UK primary care: a qualitative study

BACKGROUND

Atrial fibrillation (AF) affects up to 2% of the UK population. AF is a potentially long-term condition that needs management, and as such primary care pharmacists may have a substantial role in supporting the management of AF.

OBJECTIVES

This study aims to explore the role of primary care pharmacists, working in community pharmacies and general practices (GPs), in supporting the management of AF. Furthermore, this study investigates pharmacists' confidence in their knowledge and their attitudes towards incorporating AF-associated mobile apps use into their current practice.

METHODS

A qualitative study was conducted, using one-to-one semi-structured, audio-recorded interviews with primary care pharmacists. The topic guide was developed based on pharmacy visits and included the most relevant constructs from the 'consolidated framework for implementation research (CFIR)'. All interviews were audio-recorded, transcribed verbatim and thematically analysed until saturation was achieved, guided by Braun and Clarke's 6-step research method. This study was given a favourable opinion on 5 September 2019 by the University of Birmingham (UOB) Research Ethics Committee (Reference ERN_19-0908).

RESULTS

Thematic saturation was achieved after 11 interviews with primary care pharmacists (seven community pharmacists, and four GP pharmacists). Three main themes emerged relating to (1) the clinical role of pharmacists in the management of AF; (2) knowledge and awareness; and (3) prioritisation of resources. The first highlighted that primary care pharmacists were an underutilised resource within AF management. The second demonstrated that pharmacists, especially those based in the community, felt a lack of confidence in their knowledge of AF and its management, mainly community pharmacists due to other roles taking precedence over clinical roles. Both community and GP pharmacists expressed the need to have further training in this therapeutic area to be able to effectively support patients with AF. The third shed light on the pharmacists' views relating to the technological revolution in healthcare. Pharmacists expressed an interest in using apps to support their current practice.

CONCLUSIONS

Primary care pharmacists supported an extended care to AF management from screening to consultations, yet the provision of such services remains limited and inconsistent. Future research should focus on understanding the ways in which pharmacists' role can be adapted toward greater involvement in clinical care.

Environmental conditions, mobile digital culture, mobile usability, knowledge of app in COVID-19 risk mitigation: A structural equation model analysis

INTRODUCTION

The mobile digital culture (MDC) supports individual lives, communities, and real-time organizational surveillance during COVID-19 emergencies. Hence, the study examined the advancement in smart health devices evidence in smartphone apps technologies in surveillance, control, and tracking potential virus areas among high-risk populations.

OBJECTIVE

The study explored how environmental condition and MDC mediates between knowledge of App and mobile usability in the prevention of COVID-19 infection in high-risk areas.

METHODS

Using the concept of UTAUT, the study conceptualized that mobile usability, MDC, knowledge of App and environmental condition, are essential for COVID-19 mitigation. A cross-sectional method was adopted through an online survey to assess data from n = 459 mobile users. The association of the study models was appraised through structural equation models (Amos v.24.0).

RESULT

We found mobile usability, knowledge of App, and MDC were statistically significant to COVID-19 mitigation. Environment condition as mediator had no effect in the study models. However, moderating effect of MDC shows a negative influence on the association between COVID-19 mitigation and knowledge of apps.

CONCLUSION

Future policies should consider the development of mHealth technology to improve end-user experience. Also, future policies should entail data privacy to reduce the infringement of data collected. This approach will lead to a confidential, high acceptance of usability of mHealth apps infectious disease prevention.

Measuring Mobile Phone Application Usability for Anticoagulation from the Perspective of Patients, Caregivers, and Healthcare Professionals

Oral anticoagulants (OAC) are recommended for preventing stroke and systemic embolism in atrial fibrillation. Proper use is imperative for maximizing anticoagulation therapy's effectiveness and safety. In preparation for the implementation of a smartphone-based SmartMed app (application) aiming to promote patient self-management, medication adherence, and data collection for patients on anticoagulation therapy, its usability assessment can ensure the value of OAC app development and adoption. We evaluated the SmartMed app's usability using the System Usability Scale (SUS) and the app-specific domain of the Mobile App Rating Scale (MARS) for its perceived impact on taking OAC regularly. We recruited 25 OAC users and their home caregivers and 59 healthcare professionals, including pharmacists, nurses, and cardiac surgeons from one medical center and one regional hospital in Taiwan. All participants (n = 84) thought the SmartMed app was useful, with mean SUS and MARS scores of 81.49 (±14.42) and 4.65 (±0.49), respectively. Usability evaluation revealed that fewer experiences with smartphone apps and different healthcare professionals (pharmacists versus nurses or cardiac surgeons) were associated with lower SUS scores and perceived impact. Throughout the evaluation process, the SmartMed app's design was considered helpful from multiple stakeholders' perspectives. Further ongoing mobile technology supports are necessary to establish the SmartMed app's effectiveness.

Digital tools in allergy and respiratory care

Patient care in the allergy and respiratory fields is advancing rapidly, offering the possibility of the inclusion of a variety of digital tools that aim to improve outcomes of care. Impaired access to several health care facilities during the COVID-19 pandemic has considerably increased the appetite and need for the inclusion of e-health tools amongst end-users. Consequently, a multitude of different e-health tools have been launched worldwide with various registration and access options, and with a wide range of offered benefits. From the perspective of both patients and healthcare providers (HCPs), as well as from a legal and device-related perspective, several features are important for the acceptance, effectiveness,and long-term use of e-health tools. Patients and physicians have different needs and expectations of how digital tools might be of help in the care pathway. There is a need for standardization by defining quality assurance criteria. Therefore, the Upper Airway Diseases Committee of the World Allergy Organization (WAO) has taken the initiative to define and propose criteria for quality, appeal, and applicability of e-health tools in the allergy and respiratory care fields from a patient, clinician, and academic perspective with the ultimate aim to improve patient health and outcomes of care.

Mobile health technology in atrial fibrillation

INTRODUCTION

Mobile health (mHealth) solutions in atrial fibrillation (AF) are becoming widespread, thanks to everyday life devices such as smartphones. Their use is validated both in monitoring and in screening scenarios. In the published literature, the diagnostic accuracy of mHealth solutions wide differs, and their current clinical use is not well established in principal guidelines.

AREAS COVERED

mHealth solutions have progressively built an AF-detection chain to guide patients from the device's alert signal to the health care practitioners' (HCPs) attention. This review aims to critically evaluate the latest evidence regarding mHealth devices and the future possible patient's uses in everyday life.

EXPERT OPINION

The patients are the first to be informed of the rhythm anomaly, leading to the urgency of increasing the patients' AF self-management. Furthermore, HCPs need to update themselves about mHealth devices use in clinical practice. Nevertheless, these are promising instruments in specific populations, such as post-stroke patients, to promote an early arrhythmia diagnosis in the post-ablation/cardioversion period, allowing checks on the efficacy of the treatment or intervention.

Optimizing adherence and persistence to non-vitamin K antagonist oral anticoagulant therapy in atrial fibrillation

Atrial fibrillation (AF) is associated with an increased risk of stroke, which can be prevented by the use of oral anticoagulation. Although non-vitamin K antagonist oral anticoagulants (NOACs) have become the first choice for stroke prevention in the majority of patients with non-valvular AF, adherence and persistence to these medications remain suboptimal, which may translate into poor health outcomes and increased healthcare costs. Factors influencing adherence and persistence have been suggested to be patient-related, physician-related, and healthcare system-related. In this review, we discuss factors influencing patient adherence and persistence to NOACs and possible problem solving strategies, especially involving an integrated care management, aiming for the improvement in patient outcomes and treatment satisfaction.

Patient perspectives of the Self-management and Educational Technology tool for Atrial Fibrillation (SETAF): A mixed-methods study in Singapore

BACKGROUND

Atrial fibrillation (AF) is the most common arrythmia and is associated with costly morbidity such as stroke and heart failure. Mobile health (mHealth) has potential to help bridge the gaps of traditional healthcare models that may be poorly suited to the sporadic nature of AF. The Self-management and Educational technology support Tool for AF patients (SETAF) was designed based on the preferences and needs of AF patients but more study is required to assess the acceptance of this novel tool.

OBJECTIVE

Explore the usability and acceptance of SETAF among AF patients in Singapore.

METHODS

A mixed methods study was conducted with AF patients who were purposively sampled from an outpatient cardiology clinic in Singapore. After 6 weeks of using SETAF, semi-structured interviews were performed, and data were analyzed inductively following a thematic analysis approach. Results from a short 4-item survey and application usage data were also analyzed descriptively. Both qualitative and quantitative results were organized and presented following the Technology Acceptance Model (TAM) framework.

RESULTS

A total of 37 patients participated in the study and 19 were interviewed. Participants perceived SETAF as useful for improving AF knowledge, self-management and access to healthcare providers and was easy to use due to the guided tutorial and user-friendly interface. They also identified the need for better personalization of content, psychosocial support features and reduction of language barriers. Application usage data revealed preference for AF related content and decreased interaction with the motivational message component of SETAF over time. Overall, most of the participants would continue using SETAF and were willing to pay for it.

CONCLUSIONS

AF patients in Singapore found SETAF useful and acceptable as a tool for AF management. The insights from this study not only support the potential of mHealth but may also inform the design and implementation of future mHealth tools for AF patients.

COVID-19 smart surveillance: Examination of Knowledge of Apps and mobile thermometer detectors (MTDs) in a high-risk society

BACKGROUND

Technological innovations gained momentum and supported COVID-19 intelligence surveillance among high-risk populations globally. We examined technology surveillance using mobile thermometer detectors (MTDs), knowledge of App, and self-efficacy as a means of sensing body temperature as a measure of COVID-19 risk mitigation. In a cross-sectional survey, we explored COVID-19 risk mitigation, mobile temperature detectable by network syndromic surveillance mobility, detachable from clinicians, and laboratory diagnoses to elucidate the magnitude of community monitoring.

MATERIALS AND METHODS

In a cross-sectional survey, we create in-depth comprehension of risk mitigation, mobile temperature Thermometer detector, and other variables for surveillance and monitoring among 850 university students and healthcare workers. An applied structural equation model was adopted for analysis with Amos v.24. We established that mobile usability knowledge of APP could effectively aid in COVID-19 intelligence risk mitigation. Moreover, both self-efficacy and mobile temperature positively strengthened data visualization for public health decision-making.

RESULTS

The algorithms utilize a validated point-of-center test to ascertain the HealthCode scanning system for a positive or negative COVID-19 notification. The MTD is an alternative personal self-testing procedure used to verify temperature rates based on previous SARS-CoV-2 and future mobility digital health. Personal self-care of MTD mobility and knowledge of mHealth apps can specifically manage COVID-19 mitigation in high or low terrestrial areas. We found mobile usability, mobile self-efficacy, and app knowledge were statistically significant to COVID-19 mitigation. Additionally, interaction strengthened the positive relationship between self-efficacy and COVID-19. Data aggregation is entrusted with government database agencies, using natural language processing and machine learning mechanisms to validate and analyze.

CONCLUSION

The study shows that temperature thermometer detectors, mobile usability, and knowledge of App enhanced COVID-19 risk mitigation in a high or low-risk environment. The standardizing dataset is necessary to ensure privacy and security preservation of data ethics.

Considerations for the Assessment of Substrates, Genetics and Risk Factors in Patients with Atrial Fibrillation

Successful translation of research focussing on atrial arrhythmogenic mechanisms has potential to provide a mechanism-tailored classification and to support personalised treatment approaches in patients with AF. The clinical uptake and clinical implementation of new diagnostic techniques and treatment strategies require translational research approaches on various levels. Diagnostic translation involves the development of clinical diagnostic tools. Additionally, multidisciplinary teams are required for collaborative translation to describe genetic mechanisms, molecular pathways, electrophysiological characteristics and concomitant risk factors. In this article, current approaches for AF substrate characterisation, analysis of genes potentially involved in AF and strategies for AF risk factor assessment are summarised. The authors discuss challenges and obstacles to clinical translation and implementation into clinical practice.

Risk factor management of atrial fibrillation using mHealth: The Atrial Fibrillation – Helping Address Care with Remote Technology (AF-HEART) Pilot Study

Background

Personalized treatment of atrial fibrillation (AF) risk factors using mHealth and telehealth may improve patient outcomes.

Objective

The purpose of this study was to assess the feasibility of the Atrial Fibrillation Helping Address Care with Remote Technology (AF-HEART) intervention on the following patient outcomes: (1) heart rhythm tracking; (2) weight, alcohol, blood pressure (BP), and sleep apnea reduction; (3) AF symptom reduction; and (4) quality-of-life (QOL) improvement.

Methods

A total of 20 patients with AF undergoing antiarrhythmic therapy, cardioversion, and/or catheter ablation were enrolled and followed for 6 months. The AF-HEART intervention included remote heart rhythm, weight, and BP tracking; televisits with a dietician focusing on AF risk factors; and referrals for sleep apnea and hypertension treatment.

Results

Patients transmitted a median of 181 rhythm recordings during the 6-month follow-up period. Patients lost an average of 3.5 kilograms at 6 months (P = .005). Patients had improved SF-12 scores (P = .01), AFSS score (P = .01), EQ-5D score (P = .006), and AFEQT Global Score (P = .03). There was significant correlation between weight loss and decrease in symptom severity (r = -0.45, P = .05), and between % weight loss and decrease in symptom severity (r = -0.49, P = .03).

Conclusion

This study described the feasibility of the AF-HEART intervention for (1) consistent remote tracking of heart rhythm, weight, and BP; (2) achievement of weight loss; (3) reduction of symptoms; and (4) improvement in QOL. Expansion to a larger randomized study is planned.

One-year Follow-up Results of the Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry

BACKGROUND

The high prevalence of atrial fibrillation (AF) in the very elderly population (aged >80 years) might be underestimated. The elderly are at increased risk of both fatal stroke and bleeding. The Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry provides contemporary management strategies among the elderly Chinese patients in the new era of non-vitamin K antagonists.

OBJECTIVE

To present the 1-year follow-up data from the ChiOTEAF registry, focusing on the use of antithrombotic therapy, rate vs. rhythm control strategies, and determinants of mortality and stroke.

METHODS

The ChiOTEAF registry analyzed consecutive AF patients presenting in 44 centers from 20 Chinese provinces from October 2014 to December 2018. Endpoints of interest were mortality, thromboembolism, major bleedings, cardiovascular comorbidities, and hospital re-admissions.

RESULTS

Of the 7077 patients enrolled at baseline, 657 patients (9.3%) were lost to the follow-up and 435 deaths (6.8%) occurred. The overall use of anticoagulants remains low, approximately 38% of the entire cohort at follow-up, with similar proportions of vitamin K antagonists (VKA) and non-vitamin K antagonists (NOACs). Antiplatelet therapy was used in 38% of the entire cohort at follow-up, and more commonly among high-risk patients (41%). Among those on a NOAC at baseline, 22.4% switched to antiplatelet therapy alone after one year.Independent predictors of stroke/transient ischemic attack/peripheral embolism and/or mortality were age, heart failure, chronic kidney disease, prior ischemic stroke, dementia, and chronic obstructive pulmonary disease.

CONCLUSIONS

The ChiOTEAF registry provides contemporary data on AF management, including stroke prevention. The poor adherence of NOACs and common use of antiplatelet in these high-risk elderly population calls for multiple comorbidities management.

Beyond the 2020 guidelines on atrial fibrillation of the European society of cardiology

The most recent atrial fibrillation (AF) guidelines delivered by European Society of Cardiology (ESC) offer an updated approach to AF management, with the perspective of improved characterization of the arrhythmia, the cardiac substrate and the patients profile in terms of associated risk factors and comorbidities. Recommendations were based on careful scrutiny and assessment of all available evidence with the final aim to offer to practitioners a lower level of uncertainty in the complex process of decision making for patients with AF. The 2020 ESC guidelines on AF propose a paradigm shift in the clinical approach to AF patients, moving from a single-domain AF classification to comprehensive characterization of AF patients. Given the complex nature of AF, an integrated holistic management of AF patients is suggested by the guidelines for improving patients outcomes through the formal introduction of the CC (Confirm AF and Characterize AF) to ABC (Atrial fibrillation Better Care) pathway. In line with this concept, these new guidelines underline the importance of a more comprehensive management of AF patients which should not be limited to simply prescribe oral anticoagulation or decide between a rhythm or rate control strategy. Indeed, each step of the ABC pathway represents one of the pivotal pillars in the management of AF and only a holistic approach has the potential to improve patients' outcomes. In this review we will discuss the background that supports some of the new recommendations of 2020 ESC guidelines, with important implications for daily management of AF patients.

Current trends in the use of anticoagulant pharmacotherapy in the United Kingdom are changes on the horizon?

INTRODUCTION

Effective stroke prevention with oral anticoagulation (OAC) reduces the risk of stroke and death among patients with atrial fibrillation (AF). For most patients with AF, treatment options include vitamin K antagonists (VKA) or non-vitamin K antagonist oral anticoagulants (NOACs). NOACs have been introduced as an alternative to VKAs, and their use has been steadily increasing in the United Kingdom and Europe over a decade. In randomized clinical trials, NOACs had a favorable risk-benefit profile as compared to warfarin. However, there is a concern about their long-term safety in clinical practice, especially in high-risk patients. There have been a number of registries and surveys based on the real-world patients with AF which has been conducted and published, providing data on contemporary AF management.

AREAS COVERED

In this narrative review, the authors discuss current trends in the use of OAC in the United Kingdom and Europe, considering the potential directions for future anticoagulant therapy in patients with AF.

EXPERT OPINION

The increasing prevalence of AF and AF-related comorbidities proves the need for comprehensive prevention and management strategies. The challenge is the optimization of therapy for each patient. However, there are still gaps in optimal stroke prevention, and the mortality rates remain high in patients with AF.