Impact of Achieving Blood Pressure Targets and High Time in Therapeutic Range on Clinical Outcomes in Patients With Atrial Fibrillation Adherent to the Atrial Fibrillation Better Care Pathway: A Report From the COOL‐AF Registry

Abstract

Background We aimed to determine the effect of integrating Atrial Fibrillation Better Care pathway compliance in relation to achievement of systolic blood pressure (SBP) targets and good control of time in therapeutic range (TTR) on clinical outcomes in patients with atrial fibrillation. Methods and Results We prospectively enrolled patients with nonvalvular atrial fibrillation from 27 hospitals in Thailand. All clinical outcomes were recorded. Main outcomes were the composite of all‐cause death or ischemic stroke/systemic embolism (SSE), as well as secondary outcomes of all‐cause death, SSE, major bleeding, intracranial hemorrhage, and heart failure. An SBP of 120 to 140 mm Hg was considered good blood pressure control. Target TTR was a TTR ≥65%. A total of 3405 patients were studied (mean age 67.8 years, 41.8% female). Full ABC pathway compliance was evident in 42.7%. For blood pressure control, 41.9% had SBP within target, whereas 35.9% of those on warfarin had TTR within target. The incidence rates of all‐cause death/SSE, all‐cause death, SSE, major bleeding, intracranial hemorrhage, and heart failure were 5.29, 4.21, 1.51, 2.25, 0.78, and 2.84 per 100 person‐years respectively. Adjusted hazard ratios and 95% CI of Atrial Fibrillation Better Care pathway compliance for all‐cause death/SSE, all‐cause death, and heart failure were 0.76 (0.62–0.94), 0.79 (0.62–0.99), and 0.69 (0.51–0.94), respectively, compared with noncompliance. Patients with Atrial Fibrillation Better Care compliance and SBP within target had a better outcome or TTR within target had better outcomes. Conclusions In COOL‐AF (Cohort of Antithrombotic Use and Optimal International Normalized Ratio Level in Patients With Non‐Valvular Atrial Fibrillation in Thailand), a multicenter nationwide prospective cohort of patients with atrial fibrillation, achieving SBP within target and TTR ≥ 65% has added value to Atrial Fibrillation Better Care pathway compliance in the reduction of adverse clinical outcomes in patients with atrial fibrillation.

Clinical Outcomes of Patients with Atrial Fibrillation who Survived from Bleeding Event: The Results from COOL-AF Thailand Registry

“…Indeed, the holistic approach has been associated with improved clinical outcomes, including lower mortality, stroke, and major bleeding. 23,24 A systematic review of 21 observational studies involved 96,448 patients showed that AF patients not OAC represent population at higher risk of bleeding. 5 Previous studies in AF patients with gastrointestinal bleeding who resume OAC had better subsequent ischemic outcomes.…”

“…Indeed, the holistic approach has been associated with improved clinical outcomes, including lower mortality, stroke, and major bleeding. 23 24…”

Atrial fibrillation: stroke prevention

“…This is clearly evident, for example, with respect to the importance of blood pressure (BP) control with optimal targets of 120–129 mmHg for systolic BP and <80 mmHg for diastolic BP to reduce the risk of adverse cardiovascular events, including stroke, bleeding, ICH, and hospitalisation from heart failure. 97 , 98 Hypertension burden is also closely related to the risk of other AF-associated complications such as dementia, 99 and visit-to-visit BP variability as a surrogate measure of the quality of BP control has been associated with worse outcomes in AF patients.…”

NOACs in Atrial Fibrillation Patients with Polypharmacy

“…Indeed, adherence to the guideline-recommended Atrial fibrillation Better Care pathway can modify the natural history of AF, 8 24 even in highly complex AF patients. 25…”