Introduction: Pts with atrial fibrillation (AF) are at high risk of morbidity and mortality beyond ischemic stroke. The ABC (Atrial Fibrillation Better Care) comprehensive care approach was devised to improve overall care and is endorsed by the 2020 ESC AF Guideline. The impact of the ABC pathway in a large, well-phenotyped population is unclear. Methods: ENGAGE AF-TIMI 48 was an RCT of edoxaban vs. warfarin in pts with AF and CHADS 2 score ≥2. In this exploratory analysis, pts were classified as treated according to the ABC pathway if they met all components depicted in Fig 1 . CV outcomes were compared between pts whose care was vs. was not concordant with the ABC pathway using a Cox proportional hazards model including CHA 2 DS 2 -VASc score. Randomized treatment interaction was assessed using interaction p-values. Results: Of 20,933 pts, 35% were treated concordant with the ABC pathway. These pts were younger (age <75y: 61.9% vs. 56.5%), had less frequent prior CAD (23.3% vs. 38.8%), DM (30.3% vs. 39.4%), and stroke/TIA (18.6% vs. 33.7%). Treatment consistent with the ABC pathway was associated with lower rates of stroke/SEE (HR 0.58, 95% CI 0.50-0.67), major bleeding (HR 0.71, 95% CI 0.62-0.81), MACE (HR 0.57, 95% CI 0.52-0.62), and CV death (HR 0.57, 95% CI 0.50-0.64; p<0.001 for each; Fig 2 ). Lower rates of CV events in patients treated according to the ABC pathway were generally consistent by randomized treatment. Conclusions: In this non-randomized analysis, comprehensive management of AF consistent with the ABC pathway as outlined by the 2020 ESC Guideline on AF is associated with lower adjusted rates of multiple CV outcomes including CV mortality.
It is now well established that besides being the most common sustained arrhythmia, atrial fibrillation (AF) is a major healthcare burden. Risk of debilitating stroke is increased in AF patients, but even in the absence of stroke, this population is at heightened risk of cognitive decline, depression, and dementia. The reasons for this are complex, multifactorial, and incompletely understood. One potential contributing mechanism is cerebrovascular dysfunction. Cerebral blood flow is regulated by chemical, metabolic, autoregulatory, neurogenic, and systemic factors. The dysfunction in one or more of these mechanisms may contribute to the elevated risk of cognitive decline and cerebrovascular events in AF. This short review presents the evidence for diminished cerebral blood flow, cerebrovascular carbon dioxide reactivity (i.e., cerebrovascular vasodilatory reserve), cerebral autoregulation, and neurovascular coupling in AF patients when compared to control participants in sinus rhythm. Further work is needed to understand the physiological mechanisms underpinning these observations and their clinical significance in atrial fibrillation patients.
Even in this cohort with high overall rates of oral anticoagulation use, ESC guideline-adherent antithrombotic management is associated with significantly better outcomes, including those related to mortality and TE, as well as the composite endpoint of 'cardiovascular death, any TE or bleeding'. These contemporary observations emphasize the importance of guideline implementation, and adherence to the 2012 ESC guidelines for stroke prevention in AF.
