Mobile health technology integrated care in atrial fibrillation patients according to polypharmacy: an analysis of the mAFA-II clinical trial

Abstract Background Polypharmacy is common in patients with multiple chronic long-term conditions and has been associated with adverse outcome in patients with Atrial Fibrillation (AF). The ‘Atrial fibrillation Better Care’ (ABC) pathway has been proposed to streamline an integrated care management of AF patients, and the Mobile Health Technology for Improved Screening and Optimized Integrated Care in AF (mAFA-II) prospective cluster randomised trial showed the efficacy of a mobile health (mHealth) implemented ‘ABC’ pathway (mAFA intervention) in improving prognosis of AF patients. Whether these benefits apply also to AF patients with polypharmacy is unclear. Purpose To evaluate the effect of mAFA intervention according to the presence of polypharmacy at baseline. Methods In the mAFA-II cluster randomised trial, between June 2018 and August 2019 adults with AF were enrolled in 40 centres in China; clusters were randomised in a 1:1 ratio to mAFA intervention or usual care. In this analysis, we defined polypharmacy as being treated with 5 or more drugs at baseline. The primary outcome was the composite of stroke, thromboembolism, all-cause death and rehospitalisation. We evaluated the interaction between the effect of mAFA intervention and the presence of polypharmacy at baseline on the risk of the primary outcome using multivariable Cox-regression analysis; results were expressed as adjusted Hazard Ratio (aHR) and 95% Confidence Intervals (95%CI). We also evaluated individual components of the primary outcomes as exploratory secondary endpoints. Results 3,324 patients were enrolled in the trial and included in this analysis; of these, 558 (16.8%) patients were polymedicated at baseline (mean age 71.9±12.6 years, females 44.3%); of these, 303 (54.3%) were allocated to mAFA intervention. 2,766 patients were not polymedicated (mean age 67.9±14.4 years, females 36.7%), of these 1,343 (48.5%) were allocated to mAFA intervention. Overall, patients in the polypharmacy group were older and with higher prevalence of most comorbidities and higher thromboembolic risk. The effect of mAFA intervention was similar among patients with vs. without polypharmacy on the reduction of the primary composite outcome, although with a diluted effect among polymedicated patients (adjusted Hazard Ratio [aHR] and 95% Confidence Interval [CI]: 0.34 [0.22-0.53] vs. 0.73 [0.27-1.99], p for interaction=0.166, Figure 1); similar results were observed for all-cause death and rehospitalizations. Conclusions A mHealth-technology implemented ABC pathway showed a similar effect on the reduction of the primary composite outcome among patients with and without polypharmacy. These findings support a broad application of the ABC pathway to improve outcomes in AF patients.Figure 1