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. 2025 May 12:58:101570.
doi: 10.1016/j.lanwpc.2025.101570. eCollection 2025 May.

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

Tommaso Bucci  1   2 , Katarzyna Nabradalik  1   3 , Krysztof Irlik  1   3 , Alena Shantsila  1 , Giulio Francesco Romiti  1   4 , Marco Proietti  5   6 , Wee-Siong Teo  7 , Hyung-Wook Park  8 , Wataru Shimizu  9 , Hung-Fat Tse  10 , Tze-Fan Chao  11   12 , Gregory Y H Lip  1   13   14 ; APHRS-AF Registry Investigators
Collaborators, Affiliations

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

Tommaso Bucci et al. Lancet Reg Health West Pac. .

Abstract

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.

Keywords: ABC pathway; Atrial fibrillation; Cardiovascular events; Chronic kidney disease.

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Conflict of interest statement

GFR reports consultancy for Boehringer Ingelheim and an educational grant from Anthos, outside the submitted work. No fees are directly received personally. MP is national leader of the AFFIRMO project on multimorbidity in AF, which has received funding from the European Union’s Horizon 2020 research and innovation program under grant agreement No 899871. WS has received grants from Daiichi Sankyo Co., Ltd. and Nippon Boehringer Ingelheim Co., Ltd.; and remuneration for lectures, presentations, speakers’ bureaus, manuscript writing, or educational events from Daiichi Sankyo Co., Ltd., Nippon Boehringer Ingelheim Co., Ltd., Bristol-Meyers Squibb, Bayer Yakuhin, Ltd., Pfizer Japan, Inc., Ono Pharmaceutical Co., Ltd., and Medtronic Japan Co., Ltd. HFT: is a consultant/speaker fee and research grants from for Abbott; Amgen; AstraZeneca; Bayer; BMS, Boehringer Ingelheim; Boston Scientific; Daiichi Sankyo; Medtronic; Novartis; Pfizer and Sanofi. GYHL has been a consultant and speaker for BMS/Pfizer, Boehringer Ingelheim, Anthos, and Daiichi-Sankyo. No fees are directly received personally. All the disclosures happened outside the submitted work. GYHL is a National Institute for Health and Care Research (NIHR) Senior Investigator and co-PI of the AFFIRMO project on multimorbidity in AF (grant agreement No 899871), TARGET project on digital twins for personalized management of atrial fibrillation and stroke (grant agreement No 101136244), and ARISTOTELES project on artificial intelligence for management of chronic long-term conditions (grant agreement No 101080189), which are all funded by the EU’s Horizon Europe Research and Innovation program.

Figures

Fig. 1
Fig. 1
Clinical factors associated with chronic kidney disease on multivariable logistic regression analysis. Legend: AF: Atrial Fibrillation, CI: Confidence Intervals, COPD: Chronic Obstructive Pulmonary Disease, TIA: Transient ischaemic attack.
Fig. 2
Fig. 2
Multivariable logistic regression analysis for factors associated with ABC pathway adherence (Panel A), and spline curves showing changes in ABC adherence based on the CHA2DS2-VASc scores (Panel B) and estimated glomerular filtration rate (Panel C). Legend: AF: Atrial Fibrillation, CI: Confidence Intervals, CKD: Chronic Kidney Disease, COPD: Chronic Obstructive Pulmonary Disease, TIA: Transient ischaemic attack.
Fig. 3
Fig. 3
Kaplan–Meier curves showing the risk of the primary outcome in patients with and without chronic kidney disease (Panel A), and Cox multivariable analysis of the risk of the primary outcome (Panel B). Legend: ABC: Atrial fibrillation Better Care, AF: Atrial Fibrillation, CI: Confidence Interval, COPD: Chronic Obstructive Pulmonary Disease, CKD: Chronic Kidney Disease, HR: Hazard Ratio.
Fig. 4
Fig. 4
Distribution of propensity scores before (Panel A) and after (Panel B) matching, with corresponding changes in Absolute Mean Differences (Panel C) and results from univariable and multivariable Cox regression analyses after propensity score matching (Panel D).
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