Adherence to Atrial Fibrillation Pathway Improves Outcomes

stethoscope on the ECG. Symbolic close-up photo
Authors performed a systematic review of current evidence for the use of the Atrial Fibrillation Better Care (ABC) pathway and its effect on clinical outcomes.

Adherence to the recently proposed “Atrial Fibrillation Better Care” (ABC) pathway, a holistic comprehensive management approach for patients with atrial fibrillation (AF), was associated with risk reduction in major adverse outcomes, but the pathway was adopted by only 1 in 5 patients, according to a systematic review published in Thrombosis and Haemostasis.

The ABC pathway stands on the following pillars: Avoid stroke (through the use of anticoagulants), Better symptom management, and Cardiovascular and Comorbidity management. This approach is currently recommended in a number of clinical guidelines, including those for the European Society of Cardiology (ESC) AF management.

Researchers performed a meta-analysis and systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies reporting on ABC pathway management adherence and impact on clinical outcomes in patients with AF were found by searching EMBASE and PubMed. Major outcomes included stroke, major bleeding, cardiovascular death, and all-cause death. Random-effects models were used to perform a meta-analysis of odds ratio (OR) and meta-regression, and subgroup analyses were performed to account for heterogeneity.

Among the 7 observational studies included, the pooled prevalence of ABC adherence was 21% (95% CI, 13%-34%), with a high degree of heterogeneity, due to increasing adherence to each ABC criterion. Patients adhering to ABC pathway management showed a significantly lower risk for stroke (OR, 0.55; 95% CI, 0.37-0.82) and major bleeding (OR, 0.69; 95% CI, 0.51-0.94), with moderate heterogeneity and a significantly lower risk for cardiovascular death (OR, 0.37; 95% CI, 0.23-0.58) and all-cause death (OR, 0.42; 95% CI, 0.31-0.56), with a high degree of heterogeneity.

A direct association was found between longer follow-up periods and increased effectiveness for all outcomes, while an increasing prevalence of congestive heart failure, diabetes mellitus, coronary artery disease, and stroke was associated with the ABC pathway’s reduced effectiveness for all-cause and cardiovascular death, accounting for the heterogeneity seen with those outcomes. Sensitivity analysis found no significant differences between studies.

Although this systematic review and meta-analysis has some limitations, including the retrospective and observational nature of most of the included studies, and the fact that 2 of the included studies were performed more than 10 years ago, the authors concluded that “clinical management adherent to the ABC pathway was suboptimally applied, being adopted in [1] in every [5 patients with] AF.”

Authors of the systematic review added, “Adherence to the ABC pathway was associated with a significant reduction in the risk [for] major adverse outcomes, with a significantly reduced risk [for] all-cause death, CV death, stroke and major bleeding.”

Disclosure: One study author declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of disclosures.


Romiti GF, Pastori D, Rivera-Caravaca JM, et al. 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. Published online May 21, 2021. doi:10.1055/a-1515-9630