The 'Atrial Fibrillation Better Care' pathway for integrated care of Atrial Fibrillation: A Systematic Review and Meta-Analysis

Objective: To conduct a systematic review of the current evidence on the implementation of the 'Atrial fibrillation Better Care' (ABC) pathway for the comprehensive and holistic management of patients with AF. Patients and methods: We performed a systematic review and meta-analysis, searching MEDLINE and EMBASE for studies reporting the prevalence of ABC-adherent management in patients with AF and its association with clinical outcomes (all-cause death, cardiovascular death, stroke, stroke/thromboembolism (TE), and major bleeding). Random-effects models were used to pool results from individual studies; subgroup analyses and meta-regressions were also conducted. Results: Overall, 22 studies were included (including 2 randomised trials), with >380,000 AF patients. Adherence to the ABC pathway was 23.9% (95%CI: 17.5%-31.7%), with substantial between-study heterogeneity (I2: 99.8%). Adherence was higher in European cohorts (37.9%, 95%CI: 27.8%-49.2%) and increased with advancing age. ABC pathway adherence was associated with a lower risk of all-cause death (OR: 0.49, 95%CI: 0.41-0.58, I²: 97.1%), cardiovascular death (OR: 0.46, 95%CI: 0.36-0.59, I²: 96.4%), stroke (OR: 0.65, 95%CI: 0.51-0.82, I²: 93.5%), stroke/TE (OR: 0.53, 95%CI: 0.42-0.66, I²: 91.1%) and major bleeding (OR: 0.81, 95%CI: 0.69-0.94, I²: 89.2%). The effect of the ABC pathway was consistent in clinical trials versus real-world studies, but influenced by study-level characteristics, including geographical location, mean age, prevalence of comorbidities, and estimates adjusted for potential confounders. Conclusions: Adherence to the ABC pathway remains sub-optimal in patients with AF, but is associated with substantial beneficial effects on prognosis. Our data support widespread implementation of the ABC pathway for managing patients with AF.