A European-Multicenter Network for the Implementation of Artificial Intelligence to Manage Complexity and Comorbidities of Atrial Fibrillation Patients: The ARISTOTELES Consortium

Introduction Atrial fibrillation (AF) is the most common arrhythmia worldwide, contributing significantly to morbidity, healthcare costs, and resource utilization.[ 1 ] Patients with AF face a higher mortality and morbidity from stroke, heart failure, dementia, and hospitalizations.[ 1 ] Oral anticoagulants (OACs) are the cornerstone of AF management, as they substantially reduce the risk of stroke and mortality.[ 2 ] Nevertheless, some residual risk still remains despite anticoagulation, with most AF-related mortality linked to cardiovascular causes and comorbidities rather than stroke alone.[ 2 ] [ 3 ] AF is not a yes/no homogeneous diagnosis. AF patients are often elderly, multimorbid, and frail, with associated polypharmacy, leading to “clinically complex” phenotypes or clusters. As comorbidities often cluster in different patterns, these impact on the risk of adverse outcomes and management. In the prospective GLORIA-AF registry of AF patients, the presence of clinical complexity was associated with lower odds of being prescribed with OAC (odds ratio [OR] 0.50, 95% confidence interval [CI] 0.44–0.57), higher OAC discontinuation, and with a higher risk of adverse events (hazard ratio [HR] 1.63, 95% CI 1.43–1.86).[ 4 ] Indeed, “high clinical complexity” patients defined using latent class analysis constituted 6.6% of AF patients, and was associated with higher hazards of experiencing the primary composite outcome of all-cause death and major adverse cardiovascular events (HR 1.47, 95% 1.24–1.75).[ 5 ] Comorbidities and polypharmacy have an important influence on decision-making, by conditioning either lack of prescription of OAC in patients at risk or inappropriate dosing.[ 6 ] [ 7 ] [ 8 ] Recognizing that AF management is more than simply OAC alone, and requires a holistic and integrated care approach, contemporary guidelines globally on AF management have promoted this concept, based on the Atrial fibrillation Better Care (ABC) pathway, emphasizing Anticoagulation, Better symptom management with rate or rhythm control, and Comorbidity/lifestyle management.[ 9 ] [ 10 ] [ 11 ] The ABC pathway is well supported by clinical trial and real-world evidence,[ 11 ] whereby adherence to the ABC pathway is associated with a reduction in all-cause and cardiovascular mortality, stroke, and bleeding.[ 12 ] [ 13 ] Despite this, adherence to ABC-based management remains low, whereby a meta-analysis of 14 studies revealed that only 21% (95% CI 13–34%) of AF patients were managed in accordance with the ABC pathway.[ 12 ] This perhaps highlights a critical gap in the implementation of comprehensive evidence-based care strategies. Of note, the “ABC” acronym has been modified in US guidelines (as “SOS,” i.e., Stroke, Other Comorbidities, Rate or Rhythm control)[ 14 ] and the 2024 ESC guidelines (as “CARE,” i.e., Comorbidities, Avoid stroke, Rate or rhythm control, Evaluation),[ 15 ] although these new acronyms are untested in clinical trials.[ 11 ] * The members of the ARISTOTELES consortium are mentioned in [ Supplementary Appendix ] (available in the online version). Supplementary Material Supplementary Material Publication History Received: 04 December 2024 Accepted: 27 December 2024 Article published online: 20 January 2025 © 2025. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany