Effect of telemedicine-based integrated management of atrial fibrillation in village vlinics on recurrent nonfatal events: a secondary analysis from the miracle-af trial

Background Atrial fibrillation (AF) is a growing public health concern, particularly among older adults in rural areas who face limited awareness and treatment gaps. The MIRACLE-AF cluster randomized trial (a Novel Model of Integrated Care of Older Patients with AF in Rural China) demonstrated that a telemedicine-based, village doctor-led integrated care model significantly reduced major cardiovascular events and cardiovascular mortality as well. However, its impact on the burden of recurrent nonfatal cardiovascular events remains unexplored. Purpose This analysis aimed to evaluate the effect of the MIRACLE-AF care model on the risk of recurrent nonfatal cardiovascular events. By considering multiple events per patient, this study provides a more comprehensive assessment of the intervention’s impact beyond the first event. Methods In the MIRACLE-AF trial, a total of 30 village clinics were randomly allocated to either the intervention group (telemedicine-based integrated care) or the control group (usual care). The study included 1,039 rural participants aged 65 years or older with a diagnosis of AF. The primary outcome was a composite of cardiovascular mortality, all strokes, hospitalization due to worsening heart failure or acute coronary syndrome (ACS), and emergency visits due to AF over 36 months. This secondary analysis examined the recurrent nonfatal events within the primary composite outcome, with cardiovascular death excluded. The Anderson-Gill model with frailty terms was used to evaluate the impact of the intervention on the risk of these recurrent. Results A total of 524 patients were enrolled in the intervention group and 515 in the control group). During the follow-up, 66 (12.6%) patients in the intervention group experienced 92 recurrent nonfatal cardiovascular events, compared to 97 (18.8%) patients with 124 events in the control group. The risk of recurrent nonfatal cardiovascular events was lower in the intervention group compared to the control group (HR: 0.72, 95% CI: 0.52–1.00; p= 0.050). Subgroup analyses showed consistent reductions in recurrent nonfatal cardiovascular events across prespecified subgroups, including age, sex, new or recent AF, education level and CHA2DS2-VASc score. Conclusions The observed effect size of this post-hoc analysis suggests a potential role of the intervention in reducing the risk of recurrent nonfatal cardiovascular events. By accounting for multiple nonfatal events per patient, this analysis provides deeper insights into the intervention’s impact and further highlights the potential of a telemedicine-based, village doctor-led integrated care model to enhance AF management and improve health outcomes in older rural populations.Cumulative Hazard of Recurrent events Subgroup analysis