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Open Access 16-03-2023 | Stroke | IM - ORIGINAL

Mobile health-technology integrated care in secondary prevention atrial fibrillation patients: a post-hoc analysis from the mAFA-II randomized clinical trial

Authors: Yutao Guo, Giulio Francesco Romiti, Dimitrios Sagris, Marco Proietti, Niccolò Bonini, Hui Zhang, Gregory Y. H. Lip, The mAF-App II trial investigators

Published in: Internal and Emergency Medicine | Issue 4/2023

Abstract

AF patients with history of thromboembolic events are at higher risk of thromboembolic recurrences, despite appropriate antithrombotic treatment. We aimed to evaluate the effect of mobile health (mHealth) technology-implemented ‘Atrial fibrillation Better Care’ (ABC) pathway approach (mAFA intervention) in secondary prevention AF patients. The Mobile Health Technology for Improved Screening and Optimized Integrated Care in AF (mAFA-II) cluster randomized trial enrolled adult AF patients across 40 centers in China. The main outcome was the composite outcome of stroke or thromboembolism, all-cause death, and rehospitalization. Using Inverse Probability of Treatment Weighting (IPTW), we evaluated the effect of the mAFA intervention in patients with and without prior history of thromboembolic events (i.e., ischemic stroke or thromboembolism). Among the 3324 patients enrolled in the trial, 496 (14.9%, mean age: 75.1 ± 11.4 years, 35.9% females) had a previous episode of thromboembolic event. No significant interaction was observed for the effect of mAFA intervention in patients with vs. without history of thromboembolic events [Hazard ratio, (HR): 0.38, 95% confidence interval (CI):0.18–0.80 vs. HR 0.55, 95% CI 0.17–1.76, p for interaction = 0.587); however, a trend towards lower efficacy of mAFA intervention among AF patients in secondary prevention was observed for secondary outcomes, with significant interaction for bleeding events (p = 0.034) and the composite of cardiovascular events (p = 0.015). A mHealth-technology-implemented ABC pathway provided generally consistent reduction of the risk of primary outcome in both primary and secondary prevention AF patients. Secondary prevention patients may require further specific approaches to improve clinical outcomes such as bleeding and cardiovascular events.

Trial registration: WHO International Clinical Trials Registry Platform (ICTRP) Registration number ChiCTR-OOC-17014138.

Krijthe BP, Kunst A, Benjamin EJ et al (2013) Projections on the number of individuals with atrial fibrillation in the European Union, from 2000 to 2060. Eur Heart J 34:2746–2751. https://doi.org/10.1093/eurheartj/eht280CrossRefPubMedPubMedCentral

Burdett P, Lip GYH (2022) Atrial fibrillation in the UK: Predicting costs of an emerging epidemic recognizing and forecasting the cost drivers of atrial fibrillation-related costs. Eur Heart J Qual Care Clin Outcomes 8:187–194. https://doi.org/10.1093/ehjqcco/qcaa093CrossRefPubMed

Wolf PA, Abbott RD, Kannel WB (1991) Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke 22:983–988. https://doi.org/10.1161/01.STR.22.8.983CrossRefPubMed

Hankey GJ, Patel MR, Stevens SR et al (2012) Rivaroxaban compared with warfarin in patients with atrial fibrillation and previous stroke or transient ischaemic attack: a subgroup analysis of ROCKET AF. Lancet Neurol 11:315–322. https://doi.org/10.1016/S1474-4422(12)70042-XCrossRefPubMed

Rost NS, Giugliano RP, Ruff CT et al (2016) Outcomes with edoxaban versus warfarin in patients with previous cerebrovascular events. Stroke 47:2075–2082. https://doi.org/10.1161/STROKEAHA.116.013540CrossRefPubMed

Diener H-C, Connolly SJ, Ezekowitz MD et al (2010) Dabigatran compared with warfarin in patients with atrial fibrillation and previous transient ischaemic attack or stroke: a subgroup analysis of the RE-LY trial. Lancet Neurol 9:1157–1163. https://doi.org/10.1016/S1474-4422(10)70274-XCrossRefPubMed

Easton JD, Lopes RD, Bahit MC et al (2012) Apixaban compared with warfarin in patients with atrial fibrillation and previous stroke or transient ischaemic attack: a subgroup analysis of the ARISTOTLE trial. Lancet Neurol 11:503–511. https://doi.org/10.1016/S1474-4422(12)70092-3CrossRefPubMed

Chao TF, Joung B, Takahashi Y et al (2021) Focused update consensus guidelines of the Asia Pacific Heart Rhythm Society on stroke prevention in atrial fibrillation: executive summary. Thromb Haemost 122:20–47. https://doi.org/10.1055/s-0041-1739411CrossRefPubMedPubMedCentral

January CT, Wann LS, Calkins H et al (2019) 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart. Heart Rhythm 16:e66–e93. https://doi.org/10.1016/j.hrthm.2019.01.024CrossRefPubMed

10.

Hindricks G, Potpara T, Dagres N et al (2021) 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 42:373–498. https://doi.org/10.1093/eurheartj/ehaa612CrossRefPubMed

11.

Diener H-C, Hankey GJ, Easton JD et al (2020) Non-vitamin K oral anticoagulants for secondary stroke prevention in patients with atrial fibrillation. Eur Heart J Suppl 22:I13–I21. https://doi.org/10.1093/eurheartj/suaa104CrossRefPubMedPubMedCentral

12.

Lip GYH (2017) The ABC pathway: an integrated approach to improve AF management. Nat Rev Cardiol 14:627–628. https://doi.org/10.1038/nrcardio.2017.153CrossRefPubMed

13.

Guo Y, Lane DA, Wang L et al (2020) Mobile health technology to improve care for patients with atrial fibrillation. J Am Coll Cardiol 75:1523–1534. https://doi.org/10.1016/j.jacc.2020.01.052CrossRefPubMed

14.

Lip GYH, Lane DA, Lenarczyk R et al (2022) Integrated care for optimizing the management of stroke and associated heart disease: a position paper of the European Society of Cardiology Council on Stroke. Eur Heart J 43:2442–2460. https://doi.org/10.1093/eurheartj/ehac245CrossRefPubMedPubMedCentral

15.

Guo Y, Lane DA, Wang L et al (2019) Mobile Health (mHealth) technology for improved screening, patient involvement and optimising integrated care in atrial fibrillation: The mAFA (mAF-App) II randomised trial. Int J Clin Pract. https://doi.org/10.1111/ijcp.13352CrossRefPubMed

16.

Dong J, Zhang JL, Zeng S, Li F (2020) Subgroup balancing propensity score. Stat Methods Med Res 29:659–676. https://doi.org/10.1177/0962280219870836CrossRefPubMed

17.

Cowan JC, Wu J, Hall M et al (2018) A 10 year study of hospitalized atrial fibrillation-related stroke in England and its association with uptake of oral anticoagulation. Eur Heart J 39:2975–2983. https://doi.org/10.1093/eurheartj/ehy411CrossRefPubMedPubMedCentral

18.

Seiffge DJ, de Marchis GM, Koga M et al (2020) Ischemic stroke despite oral anticoagulant therapy in patients with atrial fibrillation. Ann Neurol. https://doi.org/10.1002/ana.25700CrossRefPubMedPubMedCentral

19.

Chao TF, Lip GYH, Liu CJ et al (2018) Relationship of aging and incident comorbidities to stroke risk in patients with atrial fibrillation. J Am Coll Cardiol 71:122–132. https://doi.org/10.1016/j.jacc.2017.10.085CrossRefPubMed

20.

Bisson A, Clementy N, Bodin A et al (2017) Relationship of preexisting cardiovascular comorbidities to newly diagnosed atrial fibrillation after ischemic stroke. Stroke 48:2878–2880. https://doi.org/10.1161/STROKEAHA.117.018251CrossRefPubMed

21.

Buckley BJR, Harrison SL, Hill A et al (2022) Stroke-heart syndrome: incidence and clinical outcomes of cardiac complications following stroke. Stroke. https://doi.org/10.1161/strokeaha.121.037316CrossRefPubMed

22.

Romiti GF, Proietti M, Vitolo M et al (2022) Clinical complexity and impact of the ABC (Atrial fibrillation Better Care) pathway in patients with atrial fibrillation: a report from the ESC-EHRA EURObservational Research Programme in AF General Long-Term Registry. BMC Med 20:326. https://doi.org/10.1186/s12916-022-02526-7CrossRefPubMedPubMedCentral

23.

Guo Y, Romiti GF, Proietti M et al (2022) Mobile health technology integrated care in older atrial fibrillation patients: a subgroup analysis of the mAFA-II randomised clinical trial. Age Ageing. https://doi.org/10.1093/ageing/afac245CrossRefPubMed

24.

Yagi M, Yasunaga H, Matsui H et al (2017) Impact of rehabilitation on outcomes in patients with ischemic stroke. Stroke 48:740–746. https://doi.org/10.1161/STROKEAHA.116.015147CrossRefPubMed

25.

Willeit P, Toell T, Boehme C et al (2020) STROKE-CARD care to prevent cardiovascular events and improve quality of life after acute ischaemic stroke or TIA: a randomised clinical trial. EClinicalMedicine 25:100476. https://doi.org/10.1016/J.ECLINM.2020.100476CrossRefPubMedPubMedCentral

26.

Hou L, Li M, Wang J et al (2021) Association between physical exercise and stroke recurrence among first-ever ischemic stroke survivors. Sci Rep 11:13372. https://doi.org/10.1038/s41598-021-92736-5CrossRefPubMedPubMedCentral

27.

Towfighi A, Ovbiagele B, el Husseini N et al (2017) Poststroke depression: a Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. https://doi.org/10.1161/STR.0000000000000113CrossRefPubMed

28.

Billinger SA, Arena R, Bernhardt J et al (2014) Physical activity and exercise recommendations for stroke survivors: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 45:2532–2553. https://doi.org/10.1161/STR.0000000000000022CrossRefPubMed

29.

Burton JK, Stewart J, Blair M et al (2022) Prevalence and implications of frailty in acute stroke: systematic review and meta-analysis. Age Ageing. https://doi.org/10.1093/ageing/afac064CrossRefPubMedPubMedCentral

30.

Proietti M, Romiti GF, Raparelli V et al (2022) Frailty prevalence and impact on outcomes in patients with atrial fibrillation: a systematic review and meta-analysis of 1,187,000 patients. Ageing Res Rev. https://doi.org/10.1016/j.arr.2022.101652CrossRefPubMed

31.

Evans NR, Wall J, To B et al (2020) Clinical frailty independently predicts early mortality after ischaemic stroke. Age Ageing 49:588–591. https://doi.org/10.1093/ageing/afaa004CrossRefPubMed

32.

Tan BYQ, Ho JSY, Leow AS et al (2022) Effect of frailty on outcomes of endovascular treatment for acute ischaemic stroke in older patients. Age Ageing. https://doi.org/10.1093/ageing/afac096CrossRefPubMedPubMedCentral

33.

Marshall IJ, Wang Y, Crichton S et al (2015) The effects of socioeconomic status on stroke risk and outcomes. Lancet Neurol 14:1206–1218. https://doi.org/10.1016/S1474-4422(15)00200-8CrossRefPubMed

34.

Yadav RS, Chaudhary D, Avula V et al (2022) Social determinants of stroke hospitalization and mortality in United States’ Counties. J Clin Med 11:4101. https://doi.org/10.3390/JCM11144101/S1CrossRefPubMedPubMedCentral

35.

Lindmark A, Eriksson M, Darehed D (2022) Socioeconomic status and stroke severity: understanding indirect effects via risk factors and stroke prevention using innovative statistical methods for mediation analysis. PLoS ONE 17:0270533. https://doi.org/10.1371/JOURNAL.PONE.0270533CrossRef

36.

Addo J, Ayerbe L, Mohan KM et al (2012) Socioeconomic Status and Stroke. Stroke 43:1186–1191. https://doi.org/10.1161/STROKEAHA.111.639732CrossRefPubMed

37.

Romiti GF, Pastori D, Rivera-Caravaca JM et al (2022) Adherence to the “atrial fibrillation better care” pathway in patients with atrial fibrillation: impact on clinical outcomes—a systematic review and meta-analysis of 285,000 patients. Thromb Haemost 122:406–414. https://doi.org/10.1055/a-1515-9630CrossRefPubMed

38.

Yoon M, Yang PS, Jang E et al (2019) 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. Thromb Haemost 19:1695–1703. https://doi.org/10.1055/s-0039-1693516CrossRef

39.

Lip GY, Ntaios G (2021) Integrated care for stroke management: easy as ABC. Thromb Haemost. https://doi.org/10.1055/a-1632-1777CrossRefPubMedPubMedCentral

Title: Mobile health-technology integrated care in secondary prevention atrial fibrillation patients: a post-hoc analysis from the mAFA-II randomized clinical trial
Authors: Yutao Guo
Giulio Francesco Romiti
Dimitrios Sagris
Marco Proietti
Niccolò Bonini
Hui Zhang
Gregory Y. H. Lip
The mAF-App II trial investigators
Publication date: 16-03-2023
Publisher: Springer International Publishing
Keywords: Stroke
Care
Atrial Fibrillation
Published in: Internal and Emergency Medicine / Issue 4/2023
Print ISSN: 1828-0447
Electronic ISSN: 1970-9366
DOI: https://doi.org/10.1007/s11739-023-03249-0

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