Cognitive Function and Telemedicine-based, Village Doctor-led Care for Atrial Fibrillation

BACKGROUND AND AIMS: Cognitive impairment is common among older patients with atrial fibrillation (AF). We aimed to evaluate whether baseline cognitive function modifies the effectiveness of a telemedicine-based, village doctor-led integrated care in older patients with AF. METHODS: This was a post hoc subgroup analysis of the MIRACLE-AF cluster-randomized trial conducted across 30 village clinics in China from December 2020 to May 2024. Rural participants aged ≥65 years with AF received telemedicine-based, village doctor-led integrated AF care or usual care. Participants were categorized by baseline Mini-Mental State Examination (MMSE) score into severe cognitive impairment (MMSE <18), mild-to-moderate cognitive impairment (MMSE 18-23), and preserved cognition (MMSE ≥24). The primary outcome was a composite of cardiovascular death, all stroke, hospitalization for worsening heart failure or acute coronary syndrome, and emergency visits for AF. RESULTS: Among 1,039 participants enrolled in the MIRACLE-AF trial (mean [SD] age, 75.8 [5.7] years; 460 women [44.3%]), 1,028 (98.9%) had baseline MMSE assessed (388 with MMSE <18, 305 with MMSE 18-23, and 335 with MMSE ≥24). Compared with control, the intervention reduced the risk of the primary outcome among patients with MMSE 18-23 (adjusted hazard ratio [HR], 0.56; 95% CI, 0.34-0.92), MMSE ≥24 (adjusted HR, 0.55; 95% CI, 0.32-0.93), and MMSE <18 (adjusted HR, 0.86; 95% CI, 0.54-1.35). P for interaction was 0.336. CONCLUSION: A telemedicine-based, village doctor-led integrated care model was associated with favorable outcomes across baseline cognitive strata, warranting further evaluation among cognitively vulnerable adults with AF in rural settings. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov (identifier NCT04622514).