Multimorbidity Status Worsening and Clinical Outcomes of Patients With Atrial Fibrillation

Figures

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  Figure 1. Study Flow and Classification of Multimorbidity Status Flow diagram of patient selection and classification in the COOL-AF (Cohort of Antithrombotic Use and Optimal INR Level in Patients With Nonvalvular Atrial Fibrillation in Thailand) registry. Patients with nonvalvular atrial fibrillation were enrolled and followed up every 6 months for up to 3 years. Weighted multimorbidity score was calculated. Patients whose metabolic score at 1 year was greater than at baseline were placed in the “multimorbidity–worsening” group. Patients whose score did not increase were considered as the “multimorbidity–no change” group. Patients without follow-up data beyond 1 year or without the possibility of worsening were excluded from outcome analyses. SSE = stroke/systemic embolism.

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  Figure 2. Incidence Rates of Clinical Outcomes According to Multimorbidity Worsening Bar graphs showing incidence rates per 100 person-years of the composite outcome and individual components in patients with multimorbidity worsening compared with those with no change in multimorbidity status at 1 year. The composite outcome included all-cause death, heart failure, major bleeding, and ischemic stroke/systemic embolism (SSE). Patients with multimorbidity worsening demonstrated significantly higher rates of the composite outcome, death, and heart failure.

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  Figure 3. Association Between Multimorbidity Worsening and Clinical Outcomes Forest plot displaying unadjusted and adjusted hazard ratios for multimorbidity worsening compared with no change in multimorbidity status. Multivariable Cox proportional hazards models were adjusted for age, time since atrial fibrillation diagnosis, sex, atrial fibrillation type, symptomatic atrial fibrillation, cardiac implantable electronic devices, smoking, dementia, history of bleeding, and oral anticoagulant use (warfarin or non–vitamin K antagonist oral anticoagulants). Multimorbidity worsening was independently associated with a higher risk of the composite outcome, death, and heart failure. SSE = stroke/systemic embolism.

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  Figure 4. Multimorbidity Burden, Change in Comorbidities, and Risk of Adverse Outcomes (A) Forest plot showing adjusted hazard ratios for the composite outcome according to baseline multimorbidity burden. (B) Restricted cubic spline analysis demonstrating the relationship between the increase in the number of comorbidities from baseline to 1 year and the adjusted hazard ratio for the composite outcome. Increasing multimorbidity burden and greater worsening in comorbidities were associated with progressively higher risks of adverse clinical outcomes.

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  Figure 5. Association of ABC Pathway Adherence on Outcomes by Multimorbidity Status Forest plots demonstrating the association between adherence to the ABC (Atrial Fibrillation Better Care) pathway, as well as its component, and the composite outcome in patients with multimorbidity worsening and those with no change in multimorbidity status. ABC pathway adherence, as well as its component, was associated with a significantly lower risk of adverse outcomes in both groups, with a greater relative benefit observed in patients with multimorbidity worsening. ABC adherence with TTR = ABC adherence incorporating quality control of warfarin, assessed by time in therapeutic range.

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  Central Illustration. Dynamic Multimorbidity and Clinical Outcomes in Atrial Fibrillation This image depicts the dynamic nature of multimorbidity and its impact on clinical outcomes in patients with atrial fibrillation enrolled in the COOL-AF (Cohort of Antithrombotic Use and Optimal INR Level in Patients With Nonvalvular Atrial Fibrillation in Thailand) registry. Over 1 year of follow-up, 20.9% of patients experienced worsening multimorbidity, whereas 79.1% remained stable. Multimorbidity worsening was independently associated with a higher risk of the composite outcome of all-cause death, heart failure, major bleeding, and ischemic stroke/systemic embolism (adjusted hazard ratio [HR]: 1.39; 95% CI: 1.13-1.70). Adherence to the ABC (Atrial Fibrillation Better Care) pathway was associated with significant risk reduction in both patients with multimorbidity worsening (HR: 0.48; 95% CI: 0.32-0.73) and those with no change in multimorbidity status (HR: 0.56; 95% CI: 0.45-0.69), highlighting the protective effect of integrated, holistic AF management. AF = atrial fibrillation; OAC = oral anticoagulant.