Adherence to the ABC (atrial fibrillation better care) pathway and risk of adverse outcomes in patients with chronic kidney disease: a report from the prospective APHRS-AF registry

Background: Limited data exist on the effectiveness of the ABC (Atrial Fibrillation Better Care) pathway in reducing adverse events in Asian patients with atrial fibrillation (AF) and chronic kidney disease (CKD). Methods: A post-hoc analysis of the prospective APHRS AF Registry. Patients were divided into CKD (eGFR < 60 ml/min) and non-CKD (eGFR ≥ 60 ml/min) groups. Logistic regression assessed factors associated with CKD, oral anticoagulant (OAC) use, and rhythm control strategies. Cox regression estimated hazard ratios (HRs) for a composite outcome of all-cause mortality and major adverse cardiovascular events. Subgroup analyses evaluated outcomes by CKD severity and ABC adherence. Findings: Of 3550 patients, 1029 had CKD (mean age 75.3 ± 10.3 years, 40.3% female), and 2521 did not (66.4 ± 11.3 years, 32.3% female). CKD patients were older, more often female, had lower ABC adherence (29.5% vs. 42.1%, p < 0.001) and anticoagulation use (Odds Ratio [OR] 0.77, 95% CI 0.61–0.96), but higher warfarin use, and were less likely to receive rhythm control (OR 0.79, 95% CI 0.66–0.94) comparing to those without CKD. CKD and adherence to the ABC pathway were independently associated with higher (HR 1.90, 95% CI 1.46–2.48) and lower (HR 0.64, 95% CI 0.48–0.87) risks of the composite outcome, respectively. Adverse event risks increased with CKD severity, and ABC pathway benefits were observed irrespective of CKD. Interpretation: AF patients with CKD show lower ABC pathway adherence and high risk of adverse events. Improving adherence to integrated care approaches may improve prognosis in this patient group. Funding: This study was an independent research grant by Pfizer and Bristol Myers Squibb (BMS) to APHRS.