Discussion
Principal finding: systemic impact of AFC construction
This longitudinal analysis of 18 942 patients with AF demonstrates that institutionalisation of Atrial Fibrillation Centres significantly enhanced ABC pathway adherence, with hospital-wide implementation rates rising from 23.3% to 40% and cardiology departments achieving 60% compliance by 2023. To our knowledge, this constitutes the first empirical evidence establishing AFCs as a catalytic framework for operationalising integrated AF care. The successful implementation in our study, encompassing a diverse patient population, offers valuable insights for healthcare institutions aiming to optimise integrated AF care. The observed 0.27% monthly adherence acceleration post-AFC underscores the translational impact of structural reforms combining protocol standardisation, multidisciplinary coordination and quality monitoring. Adherence to the ABC pathway has been suboptimal globally. A meta-analysis revealed an adherence rate of 21%,16 while Chinese studies have shown rates varying from 9% to 27%.10 17 Despite these challenges, adherence has consistently led to improved outcomes and reduced healthcare costs.18 To address these issues, the AFC model emphasises high-quality, hierarchical care and the creation of a scientifically sound management system. In this study, ABC pathway adherence reached 40% hospital-wide and 60% in cardiology by 2023, indicating that AFCs play a pivotal role in improving AF care by enhancing pathway adherence.
Beyond reforms like AFCs, integrating complementary strategies could make further progress. The MIRACLE-AF trial19 demonstrated that a structured training programme for village doctors in rural China, combined with telemedicine support, significantly improved ABC pathway adherence and reduced major cardiovascular events in patients with AF. This underscores the potential of telemedicine-driven decentralised care in overcoming geographic barriers and enhancing primary care engagement. Similarly, the European STEEER-AF project20 showed that physician-targeted educational programmes improved adherence to AF guidelines, particularly for rhythm control, which was the missing component in our study. These findings suggest that supplementing centralised AFC models with decentralised interventions, such as telemedicine-supported primary care and physician training, could bridge existing gaps in treatment adherence.
The MIRACLE-AF model aligns with national health initiatives emphasising equitable access to chronic disease management. Integrating telemedicine and primary care networks into AFCs could facilitate continuous expert guidance and standardised treatment delivery. Additionally, policy-level interventions, such as incorporating ABC metrics into hospital accreditation frameworks or insurance reimbursement criteria—may incentivise compliance, particularly with anticoagulation therapy.21 A multitiered strategy, combining AFC-based specialised care, telemedicine-facilitated outreach and policy-driven incentives, could amplify the impact of AFCs and enhance long-term AF management across diverse healthcare settings.
Improvements in secondary end points: changes in ‘A’ and ‘B’ criteria
This investigation elucidates how AFCs operationalise ABC pathway adherence through structural reforms. Stroke remains a severe and prognostically unfavourable complication of AF. Recent data indicate adherence rates of 80%–90% in Europe, though lower adherence persists in Asia, elevating the risk of adverse events.22 AFCs enforce high anticoagulation standards, including the promotion of NOACs and innovative technologies such as LAAO.23 The 12.19% absolute increase in guideline-concordant anticoagulation reflects successful institutionalisation of NOACs prioritisation, with utilisation rates reaching 50%—surpassing Chinese national averages12 though lagging behind European benchmarks still. While NOACs demonstrated superior efficacy/safety profiles over VKAs in meta-analyses,24 persistent VKA use in frail elderly subgroups exposes unresolved risk–benefit dilemmas, particularly regarding psychological factors, poor physical fundamentals, renal/hepatic dysfunction and fall-related haemorrhages,25 26 which may hinder broader NOAC adoption.
Symptom control strategies are predominantly driven by rate control, as reflected in the parallel trends between the ‘B’ criterion and rate control. Rhythm control, however, has not shown progress. This discrepancy likely stems from multifactorial barriers: (1) lack of procedural accessibility, with some patients postponing ablation due to financial constraints or physical intolerance; (2) fragmented core of treatments, biased risk perceptions and lack of understanding of current indications for rhythm control by some non-cardiology professionals. The debate between these two approaches remains a focal point in the field. Historically, the 2002 AFFIRM study shifted focus to rate control as the preferred strategy,27 though subsequent research emphasised the importance of rhythm control, particularly in maintaining sinus rhythm.28 Consequently, there has been a growing emphasis on early rhythm control, particularly through catheter ablation, which is considered both safe and efficacious.29 30 A primary goal of AFCs is to advance interventional procedures. With refined ablation techniques, safer medications and multimodal approaches, rhythm control has become more achievable.
Unsatisfactory aspect: reflections of ‘C’ criterion
The stagnation of the ‘C’ criterion in this study reveals a critical gap in comprehensive AF care. Even with optimal anticoagulation and symptom control, patients with AF remain at residual cardiovascular risk, including myocardial infarction, heart failure and cardiovascular hospitalisation. The ATHERO-AF cohort demonstrated that patients with AF adhering to anticoagulation but with uncontrolled comorbidities significantly increase both cardiovascular and non-cardiovascular rehospitalisation risks.31 The residual cardiovascular risk underscores the necessity of integrating comorbidity management into holistic AF care. Current AFC models inadequately address multifactorial cardiovascular risks, particularly in non-cardiology departments. Thus, the next phase of AFC optimisation needs to focus more on combining risk factor control with standardised pharmacotherapy. AF progression is influenced by multiple risk factors, including hypertension, coronary heart disease, heart failure and diabetes.32 Additionally, hyperlipidaemia and obesity independently increase stroke risk and mortality, serving as independent risk factors for recurrence after ablation.33 These comorbidities further exacerbate the risk of AF and may be inherently connected to other risk factors, which underscores the need for continuous improvement in comorbidity and risk factor management, as AFC development evolves.
The assessment of the ‘C’ criterion relied on guideline-recommended pharmacotherapy, aligning with the ABC pathway framework but bearing retrospective constraint: (1) retrospective design restricted analysis of clinical details (such as CHD revascularisation history, dynamic lipid profiles); (2) failure to distinguish antiplatelet therapy contexts (long-term maintenance post-percutaneous coronary intervention versus acute phase) potentially overestimated CHD management quality; (3) hypertension/diabetes evaluation depended on prescription records without objective metrics (blood pressure (BP)/blood glucose target achievement). These broad criteria may explain the notably higher ‘C’ adherence compared with prior research, and the results may positively bias the overall ABC adherence rate. This suggests future studies should enhance assessment depth by refining indicators like CHD revascularisation history, dynamic lipid/BP/glucose control, standardising antiplatelet/anticoagulant indications and duration, integrating multidimensional tools and biomarkers and incorporating clinical endpoints to comprehensively evaluate efficacy.
Differences across medical disciplines
The adherence gaps between cardiology and surgical departments expose systemic fragmentation in AFC care delivery. These differences suggest that treatment approaches may vary across departments, influenced by disease types and clinical expertise. AFC construction requires multidisciplinary collaboration, as comprehensive management is reliant on cooperation among different specialties. Integrated care in clinical practice is not a solitary pursuit of a single discipline but involves joint efforts among cardiologists, internal medicine specialists and surgeons. The limited role of surgery in AFC progress underscores the need to improve medical–surgical integration, enhance surgical education and optimise outcomes for surgically hospitalised patients with AF. Moreover, contributing factors may include insufficient physician–patient education, variability in embolism/bleeding risk assessment, reliance on antiplatelet agents instead of anticoagulants and perioperative anticoagulation interruption. Within the framework of AFC development, retrospective analysis of AF cases and interdisciplinary training should be reinforced to standardise protocols and improve outcomes across departments.
Limitations
This study has several limitations. First, while demonstrating improved ABC pathway adherence, the analysis did not assess hard clinical outcomes (such as stroke incidence, mortality). Second, in terms of criteria selection, ‘A’ included LAAO, which is a class IIa recommendation in Chinese guidelines, but whether this represents an appropriate means of stroke prevention in patients with AF remains controversial, its broader application requires further validation; ‘B’ was performed by the treatment rather than by directly assessing patients’ symptoms, which potentially overestimates adherence; and ‘C’ focused on medications rather than non-pharmacological interventions. Unmeasured confounders including AF subtype, European Heart Rhythm Association (EHRA) symptom scores and lifestyle modifications (diet/exercise adherence) could not be adjusted due to retrospective constraints. Future studies should incorporate additional variables and examine factors influencing AFC effectiveness on clinical outcomes. Third, temporal biases from the COVID-19 pandemic and fluctuations in patient conditions may have influenced AF care patterns. In addition, seasonal and cyclical biases may also be included, while these factors are difficult to quantify to be included in the analysis.
