Integrated care improves outcomes in multimorbid patients with atrial fibrillation: insights from the MIRACLE-AF trial

Abstract Background The MIRACLE-AF (a Novel Model of Integrated Care of Older Patients with Atrial Fibrillation in Rural China) cluster-randomised trialdemonstrated that a telemedicine-based, village doctor-led integrated care model significantly reduced the risk of a composite cardiovascular outcome among older patients with atrial fibrillation (AF) in rural China. Multimorbidity is highly prevalent in older patients with AF and is associated with worse clinical outcomes but the impact of telemedicine-based, village doctor-led integrated care on patients with multimorbidity is uncertain. Purpose To evaluate whether the MIRACLE-AF integrated care intervention reduced adverse clinical events in patients with multimorbidity. Methods This post-hoc subgroup analysis included patients with multimorbidity from the MIRACLE-AF trial. Multimorbidity was defined as the presence of ≥2 comorbid conditions, including hypertension, hyperlipidemia, diabetes, coronary artery disease, heart failure, cardiomyopathy, peripheral arterial disease, prior stroke or systemic embolism, or liver or kidney dysfunction. In the MIRACLE-AF trial, 30 village clinics (clusters) were randomly assigned (1:1) to the intervention group (telemedicine-based, village doctor-led integrated care) or the control group (usual care). The primary outcome was a composite of cardiovascular death, all strokes, hospitalisation due to worsening heart failure or acute coronary syndrome (ACS), and emergency visits due to AF. Secondary outcomes included the individual components of the primary composite, all-cause mortality, major bleeding, and clinically relevant non-major bleeding. Cox proportional hazard models were used to estimate treatment effects, adjusting for cluster effects and baseline risk factors. Results Among the 1,039 patients in the primary analysis of the MIRACLE-AF trial (mean age 75.8 ± 5.7 years; 44.3% women), 586 patients with multimorbidity were analysed, including 301 in the intervention group and 285 in the control group. Over a median follow-up of 34 months, the annualised rate of the primary composite outcome was significantly lower in the intervention group than in the control group (7.1% vs. 12.0% per year; rate difference -4.88 percentage points, 95% CI -7.45 to -2.31,P<0.001; adjusted HR 0.63, 95% CI 0.48 to 0.83, P<0.001). Hospitalisation due to worsening heart failure or ACS was significantly reduced with the intervention (3.3% vs. 5.8% per year; rate difference -2.51% percentage points, 95% CI -4.76% to 0.26%, P = 0.0301; adjusted HR 0.62, 95% CI 0.40 to 0.96, P=0.030). Other secondary outcome did not differ significantly between groups. Conclusions In patients with AF and multimorbidity, the telemedicine-based, village doctor-led MIRACLE-AF integrated care intervention was associated with a significant reduction in the composite primary outcome, when compared with usual care.Annualised rates of clinical outcomesCumulative incidence of the primary outcome