Background
Atrial fibrillation (AF), is a common type of rapid heart rhythm disorder. As of 2019, there were approximately 59.7 million AF patients worldwide [
1]. The age-adjusted prevalence rate of AF in China is 0.74%, with respective rates of 1.83% and 1.92% in males and females in the 60-year-old population [
2]. AF patients have double the hospitalization rate compared to non-AF patients, with approximately 30% of AF patients being hospitalized at least once per year [
3], leading to a 1.5 to 2-fold increase in overall mortality [
4], which greatly increases the economic and medical burden on families and society. Anticoagulation and rhythm control treatment are important measures for reducing the risk of AF complications, and comprehensive management of upstream treatment and underlying conditions is also crucial [
5,
6]. However, due to limited patient understanding of AF and its hazards, inadequate awareness of AF anticoagulation treatment among community doctors, and the inconvenience of long-term standardized use of anticoagulant medications, most AF patients in China do not receive standardized treatment, especially anticoagulation therapy. Research has found that the anticoagulation rate among AF patients in the community is only 24% [
7]. Therefore, the standardization of AF treatment and management to prevent complications has become one of the urgent clinical problems to be addressed. With the promotion of the hierarchical diagnosis and treatment model, community hospitals have become the main battlefield for chronic disease management, and standardized management models for chronic diseases such as hypertension, diabetes, and cardiovascular diseases have gradually improved [
8‐
14]. However, the current community management of AF patients is not yet standardized, and most of them only involve warfarin anticoagulation treatment and management [
15], with limited research on comprehensive management [
16,
17]. Based on the current situation of high incidence, low awareness, non-standardized treatment, and high hazards of AF in the elderly population, this study included non-valvular atrial fibrillation (NVAF) patients over 60 years old in our hospital. Based on the existing personal health records, combined with other basic chronic disease information, the AF information records were improved, and their understanding of AF, disease management, complications, and risks were investigated. Standardized comprehensive management and follow-up were conducted to explore the effects of standardized community management of AF on improving disease awareness, standardizing AF treatment, reducing the risk of complications, and risk factors for AF patients.
Discussion
This study investigated the awareness, medication use, occurrence of complications and risks in community-dwelling elderly patients with NVAF, and provided standardized comprehensive management. The study had a follow-up loss rate of 16.8%, which was within an acceptable range, and ultimately included 243 NVAF patients.
This study showed that as high as 94.2% of AF patients had experienced at least one symptom of AF, with approximately 36.6% of patients attributing their symptoms to aging. Among them, only 28% of patients were aware of their AF condition, and only 18.1% of patients were aware of the hazards associated with AF, suggesting insufficient awareness of AF disease among elderly AF patients. Furthermore, 26.3% of patients were diagnosed with AF through means other than routine check-ups, indicating that only 1.7% of patients became aware of their AF condition after this check-up. Despite participating in regular health check-ups and receiving written reports, a large portion of elderly individuals were unaware of their AF condition. These findings suggest that community-based family doctor teams should strengthen the interpretation of health check-up results for elderly individuals in their jurisdiction, and enhance health education for AF patients, including knowledge about AF, treatment measures and their importance, as well as the necessity of regular monitoring and follow-ups.
Elderly patients often have a high prevalence of chronic comorbidities, such as hypertension, diabetes, and coronary heart disease. The aCCI quantifies disease burden by considering the number, severity, and age of comorbidities in elderly patients, with > 3 points indicating high disease burden. Some studies have that when the aCCI score is > 3, the 10-year survival rate is ≤ 77.5% [
18]. In this study, approximately 81.9% of NVAF patients had an aCCI score > 3, with an average aCCI score of 4.49 ± 1.07, suggesting a heavy burden of chronic diseases among elderly NVAF patients. Among them, approximately 43.2% had hypertension, 9.3% had diabetes, and 5.8% had heart failure. This is consistent with the results of the study conducted by Jiang J et al. [
16]. Previous studies have found that AF, heart failure, hypertension, and coronary heart disease increase the risk of stroke by more than 5 times, 4 times, 3 times, and 1 time, respectively [
19]. Therefore, it is necessary to strengthen anticoagulant treatment for AF patients with comorbidities of hypertension and heart failure, as well as control risk factors such as hypertension, heart failure, and coronary heart disease [
20]. According to the CHA
2DS
2-VASc score, approximately 93.0% of patients in this study were considered high-risk for stroke and should receive long-term anticoagulant treatment. The rate of anticoagulant use in this study population was 11.9%, which was similar with a mere 11.2% of patients with AF in China on oral anticoagulants therapy according to the RE-LY study [
21], but lower than that reported in other communities (24% [
7] or 38% [
16]), and much lower than the rates in Eastern European countries (40%) and North America (65.7%) [
21]. Therefore, efforts should continue to be made to enhance anticoagulant treatment for AF patients.
This innovative study implemented community-based standardized comprehensive management for elderly AF patients. After 6 months of management, the anticoagulation rate of elderly NVAF patients increased to 34.6%, similar to elderly NVAF patients in other communities (38%) [
16], and after 1 year of management, the anticoagulation rate (56.4%) approached that of Eastern Europe (40%) and North America (65.7%) [
21]. Studies have shown that standard-dose NOACs in Asian populations can significantly reduce the risk of stroke or systemic embolism while reducing the risk of bleeding, demonstrating good efficacy and safety [
22]. Therefore, patients taking NOACs have better medication compliance and lower discontinuation rates [
23]. Currently, NOACs are easy to purchase and affordable in the community, which is also a reason for the improvement in anticoagulation rate and NOAC usage rate among AF patients.
In addition to anticoagulation and rhythm control treatments, active management of risk factors may reduce the risk of new-onset AF and improve the success rate of AF treatment [
5]. Hypertension, diabetes, and obesity are common risk factors for AF, which also increase the risk of AF occurrence and the occurrence of AF complications, especially stroke, heart failure, and bleeding risks [
24‐
26]. In existing studies, the incidence rate of HF in persistent AF is 44% [
27], the annual incidence rate of ischemic stroke is about 2% [
28], and the annual incidence rate of myocardial infarction ranges from 0.4 to 2.5% [
29]. Therefore, the standardized community management strengthened the management of risk factors in AF patients. Results of the study also showed that after standardized community management, there was a linear increasing trend and statistical significance in the rate of blood pressure, blood sugar, and BMI control for NVAF patients. In future studies, researchers will continue to follow up to understand the impact of standardized management on the occurrence rate of complications, hospitalization rate, and mortality rate of AF patients.
This study has certain limitations. Firstly, the current management model is not yet perfect, and due to the impact of the COVID-19 pandemic, many offline activities have been replaced by online activities. In future research and promotion, it is necessary to further enrich the content of dynamic health records, standardize management details, strengthen the implementation of offline management activities, and refine follow-up indicators. Secondly, this study is a single-center small-sample study, and the samples are only sourced from elderly NVAF patients who participated in community health examinations, thus having certain limitations. In future research, multicenter studies can be conducted, and the sample size can be expanded to facilitate universal promotion of standardized management models. Finally, this study only followed up for one year, and the follow-up time was short, so it is unable to determine the impact of standardized management on the occurrence of complications in AF patients, improvement in quality of life, and long-term prognosis.
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